Assessing Nursing Sentiments on Nurse-Resident Physician Collaboration and Administrative Support in the Labor and Delivery Setting: Development and Validation of a Novel Instrument.

OBJECTIVE: To develop a survey instrument that: 1) investigates the dynamics of collaboration in multidisciplinary care units such as labor and delivery (L&D); and (2) uniquely determines the collaborative relationships between nurses and resident physicians. BACKGROUND: An effective interprofessional collaboration between healthcare providers is considered a critical component in delivering high-quality care to patients and lies at the root of ensuring positive patient outcomes. METHODS: Two samples of responses (n = 98) were collected from L&D nurses working in 2 hospitals: 1 with novel obstetrics and gynecology (OB/GYN) residency program and 1 with legacy OB/GYN residency program. Descriptive statistics and reliability statistics (Cronbach's α and item-total correlations) were calculated for each sample. RESULTS: Reliability analysis revealed strong internal consistency of the survey items in both samples even after completing single-item deletion analysis. CONCLUSIONS: Findings suggest that our 11-item instrument shows promise in effectively assessing nursing sentiments toward collaboration with resident physicians.

Molecular Profiling Practices in Pancreatic Adenocarcinoma: Academic vs Community Physicians.

Background: Pancreatic adenocarcinoma (PDAC) is relatively rare but highly aggressive, with most patients diagnosed once they have metastatic or locally invasive disease. Molecular profiling is being explored as a tool for selecting patients for targeted therapy clinical trials and for assessing whether targeted therapies may be effective in PDAC. Whether molecular profiling is being performed at both academic and community oncology clinics has yet to be examined. Here, we characterized the molecular profiling practice patterns in patients with PDAC in academic versus community practices in Denver, Colorado. Methods: We retrospectively reviewed records of all patients with refractory, metastatic PDAC who were referred to a tertiary clinical trials drug development unit in Denver between 2014 and 2019. Results: Of 77 patients, 41 (55%) were men with a mean age of 65 years (SD, 9.3). Fifty-three patients (69%) were referred from the community and 20 (26%) from academic centers; 4 (5%) were self-referred. A total of 51% received profiling prior to referral; 29 of 50 (58%) were from the community and 10 of 21 (47%) from academic settings. Guardant was the most commonly ordered test (47 of 77; 61%); FoundationOne was the second most common (40 of 77; 52%). Twenty-three of 77 patients (30%) received both Guardant and FoundationOne testing, and 3 of 77 (4%) received Caris MI Profile. One patient received a Mocha assay and another received Ascend/Clarient fluorescence in situ hybridization (FISH). Four patients were self-referred, 2 of whom underwent both Guardant and FoundationOne, 1 who underwent Guardant testing only, and 1 who did not receive any molecular profiling testing. Conclusions: This study characterizes molecular profiling practice patterns in individuals with advanced PDAC who were referred to a tertiary clinical trials drug development unit. Both academic and community physicians were found to order profiling about 50% of the time. Further research is needed to determine impact on clinical trial enrollment and detection of PDAC.

Characterization of Blood-Based Molecular Profiling in Pancreatic Adenocarcinoma.

Background: Molecular profiling is being explored in pancreatic adenocarcinoma (PDAC) as a tool to assist with early detection, prognosis, and patient selection in targeted therapy clinical trials. Due to the challenges and risks of traditional tissue biopsies in pancreatic adenocarcinoma, the utility of blood-based molecular profiling is now being explored more broadly. However, given its novelty, what value blood-based molecular profiling may provide to oncologists caring for individuals with PDAC remains unknown. Herein, we characterize the mutational landscape of metastatic PDAC using blood-based circulating tumor DNA (ctDNA) collected in patients with refractory, metastatic PDAC who were referred to an oncology drug development unit in Denver, Colorado, between August 2014 and May 2019. Methods: We retrospectively analyzed results of blood-based molecular profiling that was performed on 77 consecutive patients with metastatic PDAC who underwent Guardant-360 testing for whom results were available. Results: In our data set, 55% of patients (41/77) were men, median (SD) age was 66 (9.3) years (range, 44-83). Of 77 patients, 34 (44%) had 1 or more somatic alterations. Variants reported as being of unknown significance were not included in the analyses. The total number of alterations were 119 (nonunique) and 96 (unique). The median number of alterations per patient was 3 and the median mutant allele frequency was 0.5%. TP53 was the most commonly altered gene (29 unique alterations), followed by KRAS (27 unique alterations). Of the patients with any alteration, 34% had 1 or more actionable alterations that could be potentially targeted in a clinical trial. Conclusions: Detection of genomic alterations in ctDNA from patients with metastatic PDAC is feasible and reveals a wide range of genomic alterations, the actionability of which is being explored in clinical trials. Further investigation is needed to determine the extent to which blood-based molecular profiling can provide clinical utility in helping to select patients into clinical trials and determine its impact on survival.

Barriers to Clinical Trial Enrollment in Patients With Pancreatic Adenocarcinoma Eligible for Early-Phase Clinical Trials.

BACKGROUND: Early-phase clinical trials are critical to the advancement of cancer care, especially in patients with pancreatic ductal adenocarcinoma, given its aggressive nature and limited available therapeutic options. METHODS: A retrospective chart review of all patients with refractory or metastatic pancreatic ductal adenocarcinoma, referred to the Sarah Cannon Research Institute at HealthONE between 2014 and 2019, were reviewed. Patients who completed genomic profiling and qualified for a phase 1 trial (primarily 1a but some 1b) were identified to assess barriers to trial enrollment. RESULTS: Of 74 identified patients, 54 patients (73%) qualified for at least 1 clinical trial based on eligibility criteria and alterations detected via molecular profiling. Up to 40 industry-sponsored clinical trials were available during this time for consideration. Of the 54, 28 patients (52%) enrolled in a clinical trial, while 26 (48%) did not enroll. The most frequently cited barriers to enrollment were concerns regarding time commitment (12%), prolonged wait time for enrollment (12%), and fear of adverse events (8%). Seven of the 26 patients (27%) were lost to follow-up or had no stated reason for declining enrollment; others did not go on trial due to death/transition to hospice (n=5; 19%) or progression of disease/declining functional status (n=4; 15%). There were few statistically significant differences between patients who chose to go on trial and those who declined. CONCLUSIONS: An understanding of why eligible patients elect not to participate in early-phase clinical trials provides insight into the patient experience and can help identify misperceptions and areas for improvement in education and the clinical trial enrollment process.

Adherence to Universal Travel Screening in the Emergency Department During Epidemic Ebola Virus Disease.

BACKGROUND: During the 2014 West African Ebola Virus Disease (EVD) outbreak, the U.S. Centers for Disease Control and Prevention recommended that all emergency department (ED) patients undergo travel screening for risk factors of importing EVD. OBJECTIVES: We sought to determine the overall adherence rate to the recommended travel screening protocol and to identify factors associated with nonadherence to the protocol. METHODS: We conducted a multicenter, retrospective analysis of adherence to the travel screening program in an academic hospital and three affiliated community hospitals. A regression model identified patient and hospital factors associated with nonadherence. RESULTS: Of the 147,062 patients included for analysis, 93.7% (n = 137,834) had travel screenings completed. We identified several characteristics of patients that were most likely to be missed by the screening protocol-patients with low English proficiency, patients who arrive via ambulance or helicopter, and patients with more severe illness or injury based on initial triage acuity. CONCLUSIONS: These findings should be used to improve adherence to the travel screening protocol for future emerging infectious disease threats.

Using flow diagrams to improve tobacco cessation programs.

Purpose The purpose of this paper is to understand how the Wyoming Quit Tobacco Program (WQTP) is used by its subscribers and to better understand how WQTP might be connected to WQTP outcomes. Design/methodology/approach Provider intake and program use data corresponding to the May 2010 to March 2012 enrollment period ( n=6,168) were used. All program flows were constructed using frequencies and crosstabs, based on an initial theoretical model prepared by the program provider. Data were adjusted based on analysis that explored all possible uses beyond those specified by the provider's theoretical model. Findings Although the authors could replicate the structure - the theoretical model constructed by the provider - the authors were not able to replicate all relationships between program components. The authors also found that most individuals signed up and used web-based services. Only a few individuals finished their treatment regimens in the way they were designed to be used by the program. Originality/value This is the first case study to use a program flow method to investigate an entire comprehensive tobacco cessation program structure and delivery.

Characterizing workflow for pediatric asthma patients in emergency departments using electronic health records.

OBJECTIVE: The purpose of this study was to describe a workflow analysis approach and apply it in emergency departments (EDs) using data extracted from the electronic health record (EHR) system. MATERIALS AND METHODS: We used data that were obtained during 2013 from the ED of a children's hospital and its four satellite EDs. Workflow-related data were extracted for all patient visits with either a primary or secondary diagnosis on discharge of asthma (ICD-9 code=493). For each patient visit, eight different a priori time-stamped events were identified. Data were also collected on mode of arrival, patient demographics, triage score (i.e. acuity level), and primary/secondary diagnosis. Comparison groups were by acuity levels 2 and 3 with 2 being more acute than 3, arrival mode (ambulance versus walk-in), and site. Data were analyzed using a visualization method and Markov Chains. RESULTS: To demonstrate the viability and benefit of the approach, patient care workflows were visually and quantitatively compared. The analysis of the EHR data allowed for exploration of workflow patterns and variation across groups. Results suggest that workflow was different for different arrival modes, settings and acuity levels. DISCUSSION: EHRs can be used to explore workflow with statistical and visual analytics techniques novel to the health care setting. The results generated by the proposed approach could be utilized to help institutions identify workflow issues, plan for varied workflows and ultimately improve efficiency in caring for diverse patient groups. CONCLUSION: EHR data and novel analytic techniques in health care can expand our understanding of workflow in both large and small ED units.

A systems science approach to fatigue management in research and health care.

The purpose of this article was to highlight innovative analytic approaches in symptom science. Complex systems modeling is discussed using fatigue as an example. Fatigue is a common symptom among individuals of any age. It can be acute or chronic, and it can vary across the day and on weekends compared with weekdays. Fatigue can overlap with other symptoms, has many dimensions, and impacts daily function as well as society at large. With the complexities surrounding symptom science, innovative models are needed to advance our understanding of factors within the person, contextual and situational factors, and workplace or health care system factors that impact the symptom experience. Advances in methodologies, such as complex systems modeling, allow for more innovative methods to study the complexities of the symptom experience, design better ways to intervene and manage symptoms, and ultimately improve outcomes related to symptom management, quality of life, and health care utilization.

Working with a Statistician on a Data Analysis Plan.

The author describes collaboration between a statistician and nurse or midwife scientist to develop a data analysis plan.

Statistical Methods for Pre-Post Intervention Design.

The author provides an overview of options for statistical tests in pre-post analysis.

Evaluation of Systematic Reviews and Meta-analyses.

The author describes various ways to assess the quality of systematic reviews, particularly meta-analyses.

The Effects of the COVID-19 Pandemic on Resident Education and Burnout.

Background: The COVID-19 pandemic has impacted the residency experience for physicians across all specialties. There have been studies examining resident perspectives on changes in curriculum and clinical experiences due to the pandemic; however, little research has been conducted on how residents in different specialties interpreted their educational experience and rates of burnout during the pandemic. Methods: We extended surveys to 281 residents across 15 separate residency programs between November 17, 2020, and December 20, 2020. The questions pertained to burnout and the effects of the pandemic on their careers. Differences between general and specialty medicine resident responses were analyzed using descriptive statistics and the Mann-Whitney U test. Results: The final analysis included 105 responses (40% response rate). We received 62 surveys (59%) from general medicine residents and 43 surveys (41%) from specialty medicine residents, with a higher response rate from junior level trainees in both groups. We found no significant differences between general and specialty residents on the level of burnout, impact on clinical experience, or future career due to COVID-19, though there was a significant difference between resident groups on the perceived impact of COVID-19 on learning. Conclusion: Specialty medicine residents reported a negative perception of the pandemic's impact on their learning during residency suggesting a greater impact on training than was perceived by the general medicine residents. Residents from general and specialty medicine programs reported similar levels of burnout and similar perceptions of the pandemic's impact on their clinical experience and future career prospects. Understanding the impacts of the COVID-19 pandemic on resident education and well-being should serve graduate medical education administrators well and prepare them for future interruptions in the traditional learning process.

The Role of Confounders in Statistical Analysis.

Researchers can limit the effects of study design limitations on research findings through statistical analysis that includes crucial covariates and accounts for confounding.

Nursing opinions on collaborating with residents in new and legacy OB/GYN programs.

Collaboration among physicians and nurses is vital and has shown to lead to better patient care and improve outcomes. Our study surveyed two groups of Labor and Delivery nurses in two regionally similar community hospitals in midwestern United States: one group from a new Obstetrics and Gynecology (OB/GYN) residency program (n = 49) and another from an established (legacy) OB/GYN residency program (n = 49). The survey asked nurses from the hospital with new and legacy residency program about preparedness for working with residents, perceptions of nurse-resident-patient relationships, collaboration and opinions about how resident physicians impact patient safety. Most nurses from the legacy residency program showed positive perceptions of collaboration with the residency and institutional support. In the new OB/GYN residency program, nurses were generally neutral and showed skepticism about collaboration with OB/GYN resident physicians and institutional support. Nurses from both hospitals felt similarly in their comfort escalating issues to administration and in their satisfaction with interprofessional collaboration within Labor and Delivery units. Providing nurses with opportunities to learn about the role of new medical residents in their patient care setting as well as intentional collaboration between nursing and residency program administration might result in more effective collaboration between physician residents and nursing staff.

Investigational medications in 9,638 hospitalized patients with severe COVID-19: lessons from the "fail-and-learn" strategy during the first two waves of the pandemic in 2020.

BACKGROUND: The early surge of the novel coronavirus disease 2019 (COVID-19) pandemic introduced a significant clinical challenge due to the high case-fatality rate in absence of evidence-based recommendations. The empirical treatment modalities were relegated to historical expertise from the traditional management of acute respiratory distress syndrome (ARDS) in conjunction with off-label pharmaceutical agents endorsed under the "emergency use authorization" (EUA) paradigm by regulatory agencies. This study was designed to evaluate the insights from the "fail-and-learn" strategy in 2020 before the availability of COVID-19 vaccines and access to reliable insights from high-quality randomized controlled trials. METHODS: A retrospective, multicenter, propensity-matched, case-control study was performed on a data registry comprising 186 hospitals from a national health care system in the United States, designed to investigate the efficacy of empirical treatment modalities during the early surge of the COVID-19 pandemic in 2020. Reflective of the time-windows of the initial two surges of the pandemic in 2020, patients were stratified into "Early 2020" (March 1-June 30) versus "Late 2020" (July 1-December 31) study cohorts. Logistic regression was applied to determine the efficacy of prevalent medications (remdesivir, azithromycin, hydroxychloroquine, corticosteroids, tocilizumab) and supplemental oxygen delivery modalities (invasive vs. non-invasive ventilation) on patient outcomes. The primary outcome measure was in-hospital mortality. Group comparisons were adjusted for covariates related to age, gender, ethnicity, body weight, comorbidities, and treatment modalities pertinent to organ failure replacement. RESULTS: From a total of 87,788 patients in the multicenter data registry screened in this study, 9,638 patients were included who received 19,763 COVID-19 medications during the first two waves of the 2020 pandemic. The results showed a minimal, yet statistically significant, association with hydroxychloroquine in "Early 2020" and remdesivir in "Late 2020" with reduced odds of mortality (odds ratios 0.72 and 0.76, respectively; P = 0.01). Azithromycin was the only medication associated with decreased odds of mortality during both study time-windows (odds ratios 0.79 and 0.68, respectively; P < 0.01). In contrast, the necessity for oxygen supply showed significantly increased odds of mortality beyond the effect of all investigated medications. Of all the covariates associated with increased mortality, invasive mechanical ventilation had the highest odds ratios of 8.34 in the first surge and 9.46 in in the second surge of the pandemic (P < 0.01). CONCLUSION: This retrospective multicenter observational cohort study on 9,638 hospitalized patients with severe COVID-19 during revealed that the necessity for invasive ventilation had the highest odds of mortality, beyond the variable effects observed by administration of the prevalent EUA-approved investigational drugs during the first two surges of the early 2020 pandemic in the United States.

Use of Statistical Power Analysis in Prospective and Retrospective Research.

JOGNN's Assistant Editor for Statistics reviews the use of power analysis for manuscripts submitted for publication consideration.

Surgeons' re-operative valve replacement practices in patients with endocarditis due to drug use.

BACKGROUND: This study discerns surgeons' attitudes and practices in the determination of heart valve replacement for patients with infectious endocarditis (IE) due to intravenous drug use (IVDU). We aimed to identify the factors contributing to surgeons' decision-making process for initial and recurrent surgical heart valves and the availability of institutional guidance. METHODS: An IRB-approved, anonymous mixed-methods, open survey instrument was designed and validated with 24 questions. A convenience sample of cardiothoracic surgeons in the United States and globally resulted in a total of 220 study participants with 176 completing every question on the survey. RESULTS: A cluster analysis revealed that although surgeons can be divided into subgroups based on their previous experience with valve replacements, these groups are not perfectly homogenous, and the number of identified clusters is dependent on technique used. Analysis of variance revealed the variables that most clearly divided the surgeons into subgroups were, in order of importance, years of practice, number of valve replacements, and geography. CONCLUSIONS: Our analysis showed heterogeneity among cardiothoracic surgeons regarding how they make clinical decisions regarding re-operative valve replacement related to IE-IVDU. Therefore, an opportunity exists for interprofessional teams to develop comprehensive guidelines to decrease variability in surgical decision-making regarding valve replacement associated with IE-IVDU.

A Two-Year Longitudinal, Cross-Sectional Evaluation of Resident Physician Burnout: An Exploration of the Effects of Stress, Satisfaction, Exercise and EMR.

Background: There is a need for better understanding of trajectory of burnout in clinical training and what factors are associated with resident well-being and burnout overtime. This study examined medical resident burnout and physical activity throughout different times of the academic year, across several different medical specialties and postgraduate years (PGY), over two years. Methods: A resident wellness survey was administered throughout five different waves from summer 2018 to winter 2020. A total of 493 survey responses from seven subspecialties completed the survey. We used 474 responses for quantitative statistical analysis and 138 for qualitative thematic analysis. Results: The average response rate was 47%, and ranged between 40% (Wave 3) and 56% (Wave 1). Three analyses were conducted: the first demonstrated significantly higher Satisfaction in Wave 1 as opposed to Wave 2. The second analysis showed significant correlations between Overall, Satisfaction, and Stress scores and exercise-based questions for female, male, and primary care cohorts of residents. The third analysis showed that in 2018, interns and non-interns differed on Stress but did not differ on Satisfaction or Overall scores. Conclusions: Similar levels of satisfaction, stress, and overall well-being were reported at different times in the academic year and from year to year. Exercise was not consistently related to resident well-being outcomes. These findings suggest a need for targeted interventions based on post-graduate year, time in the academic year and well-being drivers.

A retrospective analysis of bleeding risk with rivaroxaban, enoxaparin, and aspirin following total joint arthroplasty or revision.

STUDY OBJECTIVE: Rivaroxaban, enoxaparin, and aspirin are commonly used medications for thromboprophylaxis following lower extremity joint arthroplasty or revision. Previous research has demonstrated efficacy in preventing venous thromboembolism with each medication, however, the comparative risk of bleeding between them remains poorly understood. The aim of this study was to compare the odds of bleeding between rivaroxaban, enoxaparin, and aspirin following lower extremity joint arthroplasty or revision. DESIGN: This is a 3-year retrospective cohort study. SETTING: Data were obtained from 148 facilities across 55 states and territories of the United States. PATIENTS: This study included 85,938 patients who underwent hip or knee arthroplasty or revision. INTERVENTION: Patients received enoxaparin, rivaroxaban, or aspirin as monotherapy for thromboprophylaxis. MEASUREMENTS: The primary outcome was all bleeding, classified as major or minor bleeding, occurring in the 40 days following surgery. The secondary outcome was venous thromboembolism. MAIN RESULTS: Among 85,938 patients, 10,465 received rivaroxaban, 14,047 received enoxaparin, and 61,426 received aspirin. Bleeding occurred in 126 (1.20%) patients with rivaroxaban, 253 (1.80%) with enoxaparin, and 611 (0.99%) with aspirin. There was a significant increase in odds of bleeding in the enoxaparin compared to aspirin group odds ratio (OR) 1.18, 95% confidence interval (CI) 1.01-1.38, p = 0.042), and a trend toward increased odds of bleeding in rivaroxaban compared to aspirin group (OR 1.21, 95% CI 0.99-1.47, p = 0.058) and rivaroxaban compared to enoxaparin (OR 1.03, 95% CI 0.82-1.28, p = 0.827). Odds of venous thromboembolism were not statistically significant between all three study medications. CONCLUSIONS: Among rivaroxaban, enoxaparin, and aspirin used for thromboprophylaxis in knee and hip arthroplasty or revision, aspirin had significantly decreased odds of bleeding complications compared to enoxaparin. Although not statistically significant, aspirin also had a trend toward decreased odds of bleeding complications compared to rivaroxaban. Our study results suggest that aspirin is a safer alternative for use in postoperative thromboprophylaxis following lower extremity joint arthroplasty or revision.

A Retrospective Analysis Comparing Post-Operative Bleeding with Various Doses of Aspirin after Lower Extremity Joint Arthroplasty or Revision.

STUDY OBJECTIVE: Previous studies have shown that aspirin is noninferior to other anticoagulation therapies in preventing postoperative venous thromboembolism following lower extremity arthroplasty or revision; however, its optimal dosing for this indication is less clear. This study aims to compare the odds of bleeding between different aspirin dosages following lower extremity joint arthroplasty or revision. DESIGN: This is a 3-year retrospective multi-center cohort study across the United States and its territories. SETTING: This study included patients admitted for total hip or knee arthroplasty or revision and were treated with prophylactic aspirin. PATIENTS, INTERVENTION, MEASUREMENTS: Patients were assigned to groups based on a total daily aspirin dose of 81, 162, 325, or 650 mg. Data were analyzed for postsurgical bleeding and thromboembolism events occurring during the initial admission and up to 40 days following surgery. Other exploratory variables included type of surgery, hip or knee arthroplasty, length of stay, and patient demographic data. MAIN RESULTS: Among 53,848 patients receiving aspirin, 3922 received a total daily dose of 81 mg, 19,341 received a total daily dose of 162 mg, 5256 received a total daily dose of 325 mg, and 25,329 received a total daily dose of 650 mg. Bleeding occurred in 466 (0.87%) patients and venous thromboembolism (VTE) in 209 patients (0.39%). The odds of bleeding were compared using logistic regression, with the 650-mg dose as the reference group. None were statistically significant for bleeding between all studied aspirin doses: 81 mg (OR 1.12, 95% CI 0.83-1.51, p = 0.451), 162 mg (OR 0.83, 95% CI 0.67-1.03, p = 0.097), and 325 mg (OR 0.83, 95% CI 0.59-1.13, p = 0.245). The odds of VTE were also not statistically significant: 81 mg (OR 0.71, 95% CI 0.40-1.17, p = 0.181), 162 mg (OR 0.75 95% CI 0.54-1.03, p = 0.072), and 325 mg (OR 1.00, 95% CI 0.64-1.53, p = 0.989). CONCLUSIONS: There were no significant differences in the odds of bleeding or venous thromboembolism among all studied aspirin dosages in patients receiving aspirin for thromboprophylaxis following lower extremity joint arthroplasty or revision.