Teleneurology-Enabled Determination of Death by Neurologic Criteria After Cardiac Arrest or Severe Neurologic Injury.

OBJECTIVE: To determine whether providing teleneurology (TN) consultations aiding in determination of death by neurologic criteria (DNC) to a bedside intensivist is feasible and whether timely access and expert input increase the quality of the DNC examination and identification of potential organ donors, we reviewed retrospective data related to outcomes of such consultations. METHODS: Between November 2017 and March 2019, TN consults were requested for sequential comatose patients in the intensive care unit (ICU). We recorded patients' demographic information, causes leading to coma or suspected DNC, and the results of TN consultations. We obtained data on the number of referrals to the organ bank and number of organ donors. RESULTS: Ninety-nine consults were performed with a median time from request to start of the consult of 20.2 minutes (interquartile range 5.4-65.3 minutes). Eighty consults were requested for determination of prognosis, whereas 19 consults were requested for supervision of the DNC examination. In 1 of 80 (1.2%) prognostication consults, the patient was determined by the neurologist to require assessment of DNC and was found to meet DNC criteria; determination of DNC occurred in 11 of the 19 (57.9%) consultations for a supervised DNC examination. In a comparison of the pre-TN (94 months) and post-TN (17 months) periods, there was 2.56-fold increase in the proportion of patients meeting DNC criteria who were medically suitable for donation (pre-TN 8.9% vs post-TN 21.1%, p = 0.02) and a 2.12-fold increase in the proportion of donors (pre-TN 6.14% vs post-TN 13.1%, p = 0.14). CONCLUSIONS: It is feasible to perform TN consultations for patients with severe neurologic damage and to allow expert supervision for DNC examination. Having a teleneurologist as part of the ICU assessment team helped differentiate severe neurologic deficits from DNC and was associated with increase in organ donation.

Compliance With the National SEP-1 Quality Measure and Association With Sepsis Outcomes: A Multicenter Retrospective Cohort Study.

OBJECTIVES: Many septic patients receive care that fails the Centers for Medicare and Medicaid Services' SEP-1 measure, but it is unclear whether this reflects meaningful lapses in care, differences in clinical characteristics, or excessive rigidity of the "all-or-nothing" measure. We compared outcomes in cases that passed versus failed SEP-1 during the first 2 years after the measure was implemented. DESIGN: Retrospective cohort study. SETTING: Seven U.S. hospitals. PATIENTS: Adult patients included in SEP-1 reporting between October 2015 and September 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 851 sepsis cases in the cohort, 281 (33%) passed SEP-1 and 570 (67%) failed. SEP-1 failures had higher rates of septic shock (20% vs 9%; p < 0.001), hospital-onset sepsis (11% vs 4%; p = 0.001), and vague presenting symptoms (46% vs 30%; p < 0.001). The most common reasons for failure were omission of 3- and 6-hour lactate measurements (228/570 failures, 40%). Only 86 of 570 failures (15.1%) had greater than 3-hour delays until broad-spectrum antibiotics. Cases that failed SEP-1 had higher in-hospital mortality rates (18.4% vs 11.0%; odds ratio, 1.82; 95% CI, 1.19-2.80; p = 0.006), but this association was no longer significant after adjusting for differences in clinical characteristics and severity of illness (adjusted odds ratio, 1.36; 95% CI, 0.85-2.18; p = 0.205). Delays of greater than 3 hours until antibiotics were significantly associated with death (adjusted odds ratio, 1.94; 95% CI, 1.04-3.62; p = 0.038), whereas failing SEP-1 for any other reason was not (adjusted odds ratio, 1.10; 95% CI, 0.70-1.72; p = 0.674). CONCLUSIONS: Crude mortality rates were higher in sepsis cases that failed versus passed SEP-1, but there was no difference after adjusting for clinical characteristics and severity of illness. Delays in antibiotic administration were associated with higher mortality but only accounted for a small fraction of SEP-1 failures. SEP-1 may not clearly differentiate between high- and low-quality care, and detailed risk adjustment is necessary to properly interpret associations between SEP-1 compliance and mortality.

Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes.

BACKGROUND: Sepsis is the focus of national quality improvement programs and a recent public reporting measure from the Centers for Medicare and Medicaid Services. However, diagnosing sepsis requires interpreting nonspecific signs and can therefore be subjective. We sought to quantify interobserver variability in diagnosing sepsis. METHODS: We distributed five case vignettes of patients with suspected or confirmed infection and organ dysfunction to a sample of practicing intensivists. Respondents classified cases as systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, or none of the above. Interobserver variability was calculated using Fleiss' κ for the five-level classification, and for answers dichotomized as severe sepsis/septic shock versus not-severe sepsis/septic shock and any sepsis category (sepsis, severe sepsis, or septic shock) versus not-sepsis. RESULTS: Ninety-four physicians completed the survey. Most respondents (88%) identified as critical care specialists; other specialties included pulmonology (39%), anesthesia (19%), surgery (9%), and emergency medicine (9%). Respondents had been in practice for a median of 8 years, and 90% practiced at academic hospitals. Almost all respondents (83%) felt strongly or somewhat confident in their ability to apply the traditional consensus sepsis definitions. However, overall interrater agreement in sepsis diagnoses was poor (Fleiss' κ 0.29). When responses were dichotomized into severe sepsis/septic shock versus not-severe sepsis/septic shock or any sepsis category versus not-sepsis, agreement was still poor (Fleiss' κ 0.23 and 0.18, respectively). Seventeen percent of respondents classified one of the five cases as severe sepsis/septic shock, 27.7% rated two cases, 33.0% respondents rated three cases, 19.2% rated four cases, and 3.2% rated all five cases as severe sepsis/septic shock. Among respondents who felt strongly confident in their ability to use sepsis definitions (n = 45), agreement was no better (Fleiss' κ 0.28 for the five-category classification, and Fleiss' κ 0.21 for the dichotomized severe sepsis/septic shock classification). Cases were felt to be extremely or very realistic in 74% of responses; only 3% were deemed unrealistic. CONCLUSIONS: Diagnosing sepsis is extremely subjective and variable. Objective criteria and standardized methodology are needed to enhance consistency and comparability in sepsis research, surveillance, benchmarking, and reporting.

The preventability of ventilator-associated events. The CDC Prevention Epicenters Wake Up and Breathe Collaborative.

RATIONALE: The CDC introduced ventilator-associated event (VAE) definitions in January 2013. Little is known about VAE prevention. We hypothesized that daily, coordinated spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) might prevent VAEs. OBJECTIVES: To assess the preventability of VAEs. METHODS: We nested a multicenter quality improvement collaborative within a prospective study of VAE surveillance among 20 intensive care units between November 2011 and May 2013. Twelve units joined the collaborative and implemented an opt-out protocol for nurses and respiratory therapists to perform paired daily SATs and SBTs. The remaining eight units conducted surveillance alone. We measured temporal trends in VAEs using generalized mixed effects regression models adjusted for patient-level unit, age, sex, reason for intubation, Sequential Organ Failure Assessment score, and comorbidity index. MEASUREMENTS AND MAIN RESULTS: We tracked 5,164 consecutive episodes of mechanical ventilation: 3,425 in collaborative units and 1,739 in surveillance-only units. Within collaborative units, significant increases in SATs, SBTs, and percentage of SBTs performed without sedation were mirrored by significant decreases in duration of mechanical ventilation and hospital length-of-stay. There was no change in VAE risk per ventilator day but significant decreases in VAE risk per episode of mechanical ventilation (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.42-0.97) and infection-related ventilator-associated complications (OR, 0.35; 95% CI, 0.17-0.71) but not pneumonias (OR, 0.51; 95% CI, 0.19-1.3). Within surveillance-only units, there were no significant changes in SAT, SBT, or VAE rates. CONCLUSIONS: Enhanced performance of paired, daily SATs and SBTs is associated with lower VAE rates. Clinical trial registered with www.clinicaltrials.gov (NCT 01583413).

Systems model of physician professionalism in practice.

RATIONALE: This article proposes a systems level conceptualization of physician professionalism that is embedded in and results from the characteristics of the organizations in which doctors work such as hospitals, group practices and physician organizations. AIMS AND OBJECTIVES: The goal of this study was to develop and test the systems model of professionalism. METHODS: In total, 25 interviews were conducted in Minneapolis and Miami. Job titles of the subjects included hospital presidents, medical directors, chairs of hospital departments, quality and safety directors, chief of quality improvement and practising physicians. The data from the interviews were coded and then sorted by members of the study team into major and minor themes. RESULTS: Virtually, all of the subjects were readily able to confirm aspects of the model by providing real-life examples of factors at the practice, hospital and market levels that they believed strongly influenced the extent to which physicians adhere, or fail to adhere, to the professional norms. CONCLUSIONS: The systems model of professionalism was consistent with the views and experiences of physicians and administrators in two different geographic regions of the USA. If born out by further research, this model has implications for interventions aimed at improving professionalism as well as for professionalism as a field of study.

An exploration of safety climate in nursing homes.

OBJECTIVES: Although nursing homes provide complex care requiring attention to safety, research on safety climate in nursing homes is limited. Our study assessed differences in attitudes about safety among nursing home personnel and piloted a new survey, specifically designed for the nursing home context. METHODS: Drawing on previous safety climate surveys for hospitals and nursing homes, researchers developed the Survey on Resident Safety in Nursing Homes and administered it March to June 2008 to frontline caregivers and managers in 8 randomly selected Massachusetts nursing homes. Our sample consisted of 751 employees, including all full-time, direct-care staff and managers from participating facilities. First, we performed factor analysis and determined Cronbach alphas for the Survey on Resident Safety in Nursing Homes. Then, we described facilities' safety climate and variation by personnel category and among facilities by calculating the proportion of responses that were strongly positive by item, personnel category, and nursing home. RESULTS: Of 432 respondents (57% response), 29% gave their nursing home an excellent rating overall. Scores varied by personnel category and home: 51% of senior managers gave an excellent safety grade versus 26% of nursing assistants; the range in top safety grades among nursing homes was 30 percentage points. CONCLUSIONS: Safety climate varied substantially among this small sample of nursing homes and by personnel category; managers had more positive perceptions about safety than frontline workers. Efforts to measure safety climate in nursing homes should include the full range of staff at a facility and comparisons among staff categories to provide a full understanding for decision making and to promote targeted response to improve resident safety.

Marked reduction in 30-day mortality among elderly patients with community-acquired pneumonia.

BACKGROUND: Community-acquired pneumonia is the most common infectious cause of death in the US. Over the last 2 decades, patient characteristics and clinical care have changed. To understand the impact of these changes, we quantified incidence and mortality trends among elderly adults. METHODS: We used Medicare claims to identify episodes of pneumonia, based on a validated combination of diagnosis codes. Comorbidities were ascertained using the diagnosis codes located on a 1-year look back. Trends in patient characteristics and site of care were compared. The association between year of pneumonia episode and 30-day mortality was then evaluated by logistic regression, with adjustment for age, sex, and comorbidities. RESULTS: We identified 2,654,955 cases of pneumonia from 1987-2005. During this period, the proportion treated as inpatients decreased, the proportion aged ≥80 years increased, and the frequency of many comorbidities rose. Adjusted incidence increased to 3096 episodes per 100,000 population in 1999, with some decrease thereafter. Age/sex-adjusted mortality decreased from 13.5% to 9.7%, a relative reduction of 28.1%. Compared with 1987, the risk of mortality decreased through 2005 (adjusted odds ratio, 0.46; 95% confidence interval, 0.44-0.47). This result was robust to a restriction on comorbid diagnoses assessing for the results' sensitivity to increased coding. CONCLUSIONS: These findings show a marked mortality reduction over time in community-acquired pneumonia patients. We hypothesize that increased pneumococcal and influenza vaccination rates as well as wider use of guideline-concordant antibiotics explain a large portion of this trend.

Trends in mortality and medical spending in patients hospitalized for community-acquired pneumonia: 1993-2005.

BACKGROUND: Community-acquired pneumonia (CAP) is the most common infectious cause of death in the United States. To understand the effect of efforts to improve quality and efficiency of care in CAP, we examined the trends in mortality and costs among hospitalized CAP patients. METHODS: Using the National Inpatient Sample between 1993 and 2005, we studied 569,524 CAP admissions. The primary outcome was mortality at discharge. We used logistic regression to evaluate the mortality trend, adjusting for age, gender, and comorbidities. To account for the effect of early discharge practices, we also compared daily mortality rates and performed a Cox proportional hazards model. We used a generalized linear model to analyze trends in hospitalization costs, which were derived using cost-to-charge ratios. RESULTS: Over time, length of stay declined, while more patients were discharged to other facilities. The frequency of many comorbidities increased. Age/gender-adjusted mortality decreased from 8.9% to 4.1% (P < 0.001). In multivariable analysis, the mortality risk declined through 2005 (odds ratio, 0.50; 95% confidence interval, 0.48-0.53), compared with the reference year 1993. The daily mortality rates demonstrated that most of the mortality reduction occurred early during hospitalization. After adjusting for early discharge practices, the risk of mortality still declined through 2005 (hazard ratio, 0.74; 95% confidence interval, 0.70-0.78). Median hospitalization costs exhibited a moderate reduction over time, mostly because of reduced length of stay. CONCLUSIONS: Mortality among patients hospitalized for CAP has declined. Lower in-hospital mortality at a reduced cost suggests that pneumonia is a case of improved productivity in health care.

Patient safety climate in hospitals: act locally on variation across units.

BACKGROUND: An appreciation of how human factors affect patient safety has led to development of safety climate surveys and recommendations that hospitals regularly assess safety attitudes among caregivers. A better understanding of variation in patient safety climate across units within hospitals would facilitate internal efforts to improve safety climate. A study was conducted to assess the extent and nature of variation in safety climate across units within an academic medical center. METHODS: The Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety was administered in 2008 to all nurses and attending physicians (N=4283) in a 900-bed acute care hospital (overall response rate, 69% [n=2961]). Responses were analyzed from the 2,163 physicians and nurses (73% of respondents) who could be assigned to one specific clinical unit. Results were examined for 57 units, categorized into six types. RESULTS: Ratings of various safety climate domains differed markedly across the 57 units, with the percentage reporting a safety grade of excellent ranging from 0% to 50%. The overall percentage of positive ratings was lower for the operating and emergency unit types than for inpatient medical and other clinical units. Even within the six unit types, substantial variation across individual units was evident. Unlike previous findings, physicians reported more negative ratings than nurses for some safety climate dimensions. CONCLUSIONS: Safety climate may vary markedly within hospitals. Assessments of safety climate and educational and other interventions should anticipate considerable variation across units within individual hospitals. Furthermore, clinicians at individual hospitals may offer different relative perceptions of the safety climate than their professional peers at other hospitals.

Handoffs causing patient harm: a survey of medical and surgical house staff.

BACKGROUND: Communication lapses at the time of patient handoffs are believed to be common, and yet the frequency with which patients are harmed as a result of problematic handoffs is unknown. Resident physicians were surveyed about their handoffpractices and the frequency with which they perceive problems with handoffs lead to patient harm. METHODS: A survey was conducted in 2006 of all resident physicians in internal medicine and general surgery at Massachusetts General Hospital (MGH) concerning the quality and effects of handoffs during their most recent inpatient rotations. Surveys were sent to 238 eligible residents; 161 responses were obtained (response rate, 67.6%). RESULTS: Fifty-nine percent of residents reported that one or more patients had been harmed during their most recent clinical rotation because of problematic handoffs, and 12% reported that this harm had been major. Overall quality of handoffs was reported to be fair or poor by 31% of residents. A minority of residents (26%) reported that handoffs usually or always took place in a quiet setting, and 37% reported that one or more interruptions during the receipt of handoffs occurred either most of the time or always. DISCUSSION: Although handoffs have long been recognized as potentially hazardous, further scrutiny of handoffs has followed recent reports that handoffs are often marked by missing, incomplete, or inaccurate information and are associated with adverse events. In this study, reports of harm to patients from problematic handoffs were common among residents in internal medicine and general surgery. Many best-practice recommendations for handoffs are not observed, although the extent to which improvement of these practices could reduce patient harm is not known. MGH has recently launched a handoff-safety educational program, along with other interventions designed to improve the safety and effectiveness of handoffs, for its house staff and clinical leadership.

The Accreditation Council for Graduate Medical Education's limits on residents' work hours and patient safety. A study of resident experiences and perceptions before and after hours reductions.

BACKGROUND: Limiting resident work hours may improve patient safety, but unintended adverse effects are also possible. We sought to assess the impact of Accreditation Council for Graduate Medical Education resident work hour limits implemented on July 1, 2003, on resident experiences and perceptions regarding patient safety. METHODS: All trainees in 76 accredited programs at 2 teaching hospitals were surveyed in 2003 (preimplementation) and 2004 (postimplementation) regarding their work hours and patient load; perceived relation of work hours, patient load, and fatigue to patient safety; and experiences with adverse events and medical errors. Based on reported weekly duty hours, 13 programs experiencing substantial hours reductions were classified into a "reduced-hours" group. Change scores in outcome measures before and after policy implementation in the reduced-hours programs were compared with those in "other programs" to control for temporal trends, using 2-way analysis of variance with interaction. RESULTS: A total of 1770 responses were obtained (response rate, 60.0%). Analysis was restricted to 1498 responses from respondents in clinical years of training. Residents in the reduced-hours group reported significant reductions in mean weekly duty hours (from 76.6 to 68.0 hours, P < .001), and the percentage working more than 80 hours per week decreased from 44.0% to 16.6% (P < .001). No significant increases in patient load while on call (patients admitted, covered, or cross covered) were observed. Between 2003 and 2004, there was a decrease in the proportion of residents in the reduced-hours programs indicating that working too many hours (63.2% vs 44.0%; P < .001) or cross covering too many patients (65.9% vs 46.9%; P = .001) contributed to mistakes in patient care. There were no significant reductions in these 2 measures in the other group, and the differences in differences were significant (P = .03 and P = .02, respectively). The number of residents in reduced-hours programs who reported committing at least 1 medical error within the past week remained high in both study years (32.9% in 2003 and 26.3% in 2004, P = .27). CONCLUSIONS: It is possible to reduce residents' hours without increasing patient load. Doing so may reduce the extent to which fatigue affects patient safety as perceived by these frontline providers.

Residents report on adverse events and their causes.

BACKGROUND: Resident physicians are frontline providers with a unique vantage point from which to comment on patient safety-related events. METHODS: We surveyed trainees at 2 teaching hospitals about experiences with adverse events (AEs), mistakes, and near misses, as well as the potential causes. RESULTS: Responses were obtained from 821 (57%) of 1440 eligible trainees. Analysis was restricted to 689 clinical trainees. More than half (55%) reported ever caring for a patient who had an AE. The most common types of AEs were procedural and medication related. More than two thirds of AEs were considered significant. Of the most recent AEs, 24% were attributed to mistakes. The most common reasons for mistakes, as perceived by residents, were excessive work hours (19%), inadequate supervision (20%), and problems with handoffs (15%). In the last week, 114 respondents (18%) reported having a patient with an AE; of these, 42 (37%) reported AEs involving a mistake for which they considered themselves responsible. In addition, 141 (23%) reported near-miss incidents in the last week for which they considered themselves responsible. In multivariate analyses, significant predictors of AEs in the last week were inpatient rotation, duty hours in the last week, and procedural specialty. Predictors of near-miss errors in the last week were inpatient rotation, days of fatigue in the last month, and postgraduate year 1 status. CONCLUSIONS: These findings support the perception that AEs are commonly encountered by physicians and often associated with errors. Causes of errors in teaching hospitals appear to be multifactorial, and a variety of measures are necessary to improve safety. Eliciting residents' perspectives is important because residents may perceive events, actions, and causal relationships that medical record reviewers or observers cannot.

A single measure of FEV1 is associated with risk of asthma attacks in long-term follow-up.

BACKGROUND: Clinical practice guidelines for asthma care emphasize the use of objective measures of asthma severity, and yet little data exist on the relationship between FEV(1) and asthma outcomes over long-term follow-up. METHODS: We explored the association between measures of FEV(1) percentage of predicted (FEV(1)% predicted) and subsequent asthma attacks over 3-year intervals. Subjects were identified from two longitudinal cohort studies conducted in the United States and the Netherlands. Persons were included in the analysis if they reported ever having an attack of wheezing with associated shortness of breath prior to or during the follow-up period. RESULTS: Over the course of longitudinal follow-up at 3-year intervals, 195 subjects in the Netherlands cohort contributed 510 observations, and 698 subjects in the US cohort contributed 1,268 observations (for each observation, the report of an attack since their last visit was paired with the subject's FEV(1) recorded 3 years prior). Overall, subjects in the Netherlands cohort experienced 114 attacks (22% of the observations) and subjects in the US cohort had 517 attacks (40.6% of the observations). FEV(1)% predicted was significantly associated with risk of an asthma attack over the 3 years following its measurement. After adjusting for current smoking and gender, FEV1% predicted remained an independent predictor of subsequent asthma attacks. CONCLUSIONS: These findings support the use of spirometry as an objective measure of asthma severity and risk of adverse outcomes.

Association between preference-based health-related quality of life and asthma severity.

BACKGROUND: Preference-based measures of health-related quality of life (HRQL) focus on choice and strength of preference for health outcomes. If the value people attach to the health improvement they receive from medical treatments for asthma is known, preference-based measures can be used in cost-effectiveness analyses to aid resource allocation decisions. International guidelines have been developed to guide medical management according to asthma severity defined by lung function and symptom frequency. OBJECTIVE: To test the hypothesis that preferences correlate with asthma severity and that the relationships vary among the preference instruments used and the components of asthma severity studied. METHODS: Preferences for subjects' health states were measured using (1) a rating scale (RS), (2) standard gamble (SG), (3) time tradeoff (TTO), (4) Health Utilities Index 3 (HUI3), and (5) Asthma Symptom Utility Index (ASUI). We measured level of airways obstruction by forced expiratory volume in 1 second (FEV1) and symptom frequency of cough, wheeze, dyspnea, and nighttime awakening. Asthma severity was defined by either percentage of predicted FEV1 or symptom frequency. RESULTS: One hundred adults with asthma were studied. Preference scores were lowest for the HUI3 (mean, 0.57) and highest for the SG (mean, 0.91). Spearman correlations showed that the strength of the relationship between preference scores and percentage of predicted FEV1 was weak to moderate (r = 0.14-0.36). One-way analysis of variance showed that RS, TTO, and ASUI scores were significantly associated with the percentage of predicted FEV1 (P < or = .01). Both RS and HUI3 scores were significantly associated with frequency of all symptoms (P < .05). CONCLUSIONS: Preference-based measures of HRQL are correlated with asthma severity defined by lung function or symptoms. The RS was significantly associated with level of airways obstruction and all 4 symptoms evaluated, whereas the SG was not correlated with either marker of asthma severity.

A novel approach to defining the relationship between lung function and symptom status in asthma.

We present a novel approach to estimating functional relationships between forced expiratory volume in 1 second (FEV(1)) and asthma-related symptoms on a population-wide basis. We used asthma-related clinical trials that reported estimates of mean lung function (measured as FEV(1) percent predicted) and symptoms (symptom score or percentage of symptom days or nighttime awakenings). Using average baseline values from each study in weighted linear regression analyses, we found a negative association between lung function and symptom score (P < 0.001) and the percentage of nighttime awakenings (P = 0.18), but no association between lung function and symptom days. We also found consistent relationships between the mean changes in lung function and symptoms at follow-up within the studies. Functional relationships between FEV(1) percent predicted and asthma-related symptoms can be useful for inferring the effect on the symptoms of a population associated with overall improvements in lung function.