Clinical impact of intraoperative electronic health record downtime on surgical patients.

OBJECTIVE: Despite increased use of electronic health records (EHRs), the clinical impact of system downtime is unknown. MATERIALS AND METHODS: This retrospective matched cohort study evaluated the impact of EHR downtime episodes lasting more than 60 minutes over a 6-year study period. Patients age 18 years or older who underwent surgical procedures at least 60 minutes in duration with an inpatient stay exceeding 24 hours within the study period were eligible for inclusion. Out of 4115 patients exposed to 1 of 176 EHR downtime episodes, 4103 patients were matched to an unexposed cohort in a 1:1 ratio. Multivariable regression analysis, as well as trend analysis for effect of duration of downtime on outcomes, was performed. RESULTS: Downtime-exposed patients had operating room duration 1.1 times longer (p < .001) and postoperative length of stay 1.04 times longer (p = .007) compared to unexposed patients. The 30-day mortality rates were similar between these groups (odds ratio 1.26, p > .05). In trend analysis, there was no association between duration of downtime with respect to evaluated outcomes, postoperative length of stay, and 30-day mortality. CONCLUSION: EHR downtime had no impact on 30-day mortality. Potential associations for increased postoperative length of stay and duration of time spent in the operating room were observed among downtime-exposed patients. No trend effect was observed with respect to duration of downtime and postoperative length of stay and 30-day mortality rates.

Health IT Usability Focus Section: Data Use and Navigation Patterns among Medical ICU Clinicians during Electronic Chart Review.

Background A detailed understanding of electronic health record (EHR) workflow patterns and information use is necessary to inform user-centered design of critical care information systems. While developing a longitudinal medical record visualization tool to facilitate electronic chart review (ECR) for medical intensive care unit (MICU) clinicians, we found inadequate research on clinician­EHR interactions. Objective We systematically studied EHR information use and workflow among MICU clinicians to determine the optimal selection and display of core data for a revised EHR interface. Methods We conducted a direct observational study of MICU clinicians performing ECR for unfamiliar patients during their routine daily practice at an academic medical center. Using a customized manual data collection instrument, we unobtrusively recorded the content and sequence of EHR data reviewed by clinicians. Results We performed 32 ECR observations among 24 clinicians. The median (interquartile range [IQR]) chart review duration was 9.2 (7.3­14.7) minutes, with the largest time spent reviewing clinical notes (44.4%), laboratories (13.3%), imaging studies (11.7%), and searching/scrolling (9.4%). Historical vital sign and intake/output data were never viewed in 31% and 59% of observations, respectively. Clinical notes and diagnostic reports were browsed ≥10 years in time for 60% of ECR sessions. Clinicians viewed a median of 7 clinical notes, 2.5 imaging studies, and 1.5 diagnostic studies, typically referencing a select few subtypes. Clinicians browsed a median (IQR) of 26.5 (22.5­37.25) data screens to complete their ECR, demonstrating high variability in navigation patterns and frequent back-and-forth switching between screens. Nonetheless, 47% of ECRs begin with review of clinical notes, which were also the most common navigation destination. Conclusion Electronic chart review centers around the viewing of clinical notes among MICU clinicians. Convoluted workflows and prolonged searching activities indicate room for system improvement. Using study findings, specific design recommendations to enhance usability for critical care information systems are provided.

Comparative analysis of fracture characteristics of the developing mandible: the Mayo Clinic experience.

OBJECTIVE: To review and compare the epidemiology and treatment of mandibular fractures in subgroups of a pediatric population. METHODS: We conducted a retrospective review of pediatric patients (age, ≤18 years) with mandibular fractures treated at our institution from January 1996 through November 2011. RESULTS: We identified 122 patients (93 [76%] male) with 216 mandibular fractures. The prevalent mechanisms of injury were motor vehicle accidents (n=52 [43%]), sports injuries (n=24 [20%]), and assault (n=13 [11%]). The most common fracture sites were subcondylar, parasymphyseal, angle, and body. Two patients (2%) were treated conservatively by observation only, 67 (55%) underwent maxillomandibular fixation alone, 41 (34%) underwent maxillomandibular fixation with plate fixation, and 7 (5.7%) underwent plate fixation only. The average duration of maxillomandibular fixation was 26 days (range, 7-49 days). Complications occurred in 11 patients (9.0%) over a mean follow-up of 92 days (range, 21-702 days). Fifty patients (41.0%) had comorbid conditions or a history of mental illness at the time of injury, including attention deficit hyperactivity disorder (n=11 [9%]), mental disorders other than attention deficit hyperactivity disorder (n=23 [19%]), and asthma (n=17 [14%]). Twenty-six patients (21%) had a history of substance use, the most common being tobacco (n=18 [15%]), alcohol (n=13 [11%]), and marijuana (n=11 [9%]). CONCLUSIONS: Treatment approach and outcomes were affected by age and fracture characteristics. In addition, a marked proportion of this cohort had preexisting mental disorders and history of substance use, which may have implications on treatment approach.

Three-dimensional volumetric computed tomographic scoring as an objective outcome measure for chronic rhinosinusitis: clinical correlations and comparison to Lund-Mackay scoring.

BACKGROUND: We aimed to test the hypothesis that three-dimensional (3D) volume-based scoring of computed tomography (CT) images of the paranasal sinuses was superior to Lund-Mackay CT scoring of disease severity in chronic rhinosinusitis (CRS). We determined correlation between changes in CT scores (using each scoring system) with changes in other measures of disease severity (symptoms, endoscopic scoring, and quality of life) in patients with CRS treated with triamcinolone. METHODS: The study group comprised 48 adult subjects with CRS. Baseline symptoms and quality of life were assessed. Endoscopy and CT scans were performed. Patients received a single systemic dose of intramuscular triamcinolone and were reevaluated 1 month later. Strengths of the correlations between changes in CT scores and changes in CRS signs and symptoms and quality of life were determined. RESULTS: We observed some variability in degree of improvement for the different symptom, endoscopic, and quality-of-life parameters after treatment. Improvement of parameters was significantly correlated with improvement in CT disease score using both CT scoring methods. However, volumetric CT scoring had greater correlation with these parameters than Lund-Mackay scoring. CONCLUSION: Volumetric scoring exhibited higher degree of correlation than Lund-Mackay scoring when comparing improvement in CT score with improvement in score for symptoms, endoscopic exam, and quality of life in this group of patients who received beneficial medical treatment for CRS.

Anatomic evaluation of the vertical face-lift in cadavers.

IMPORTANCE: This study investigates how different orientations of tension vectors affect the amount of soft-tissue lift in specific cervicofacial regions. OBJECTIVES: To compare differences in cosmetic neck and face changes generated by 3 different face-lift techniques, to quantify the amount of lift across different points on the face, and to quantify changes in platysmal dehiscence in each of 3 standard superficial musculoaponeurotic system plication face-lift techniques applied to fresh-frozen cadaver heads. DESIGN, SETTING, AND PARTICIPANTS: Ten cadaver heads in an academic tertiary care center. INTERVENTION(S): Three different superficial musculoaponeurotic system plication rhytidectomy procedures were conducted in the following sequence: (1) vertical tension vector plication (vertical lift), (2) superolateral tension vector plication (superolateral lift), and (3) superolateral tension vector plication combined with midline platysmal plication (superolateral lift with platysmal plication). MAIN OUTCOMES AND MEASURES: After completion of each technique, the amount of lift at 4 standard key points was measured and recorded, and differences in lift at the key points were analyzed. RESULTS: Vertical lift was associated with greater total lift than superolateral lift alone or superolateral lift with platysmal plication (P < .001 for both). Platysmal dehiscence increased from baseline measurements after superolateral lift and decreased after vertical lift (P = .002 for both). CONCLUSIONS AND RELEVANCE: Our findings establish how different orientations of tension vectors applied during face-lift surgery achieve different structural changes to various key points across the face. This study helps the face-lift surgeon and student understand the underlying structural anatomic changes associated with different face-lift techniques, which ultimately result in different cosmetic outcomes. LEVEL OF EVIDENCE: NA.

Alternate and incidental diagnoses on noncontrast-enhanced spiral computed tomography for acute flank pain.

INTRODUCTION: Our aim was to determine the incidence and spectrum of significant alternate or incidental diagnoses established or suggested on spiral computed tomography (CT) in a large series of patients with suspected renal colic. MATERIALS AND METHODS: Records of all patients that had undergone spiral CT (5-mm to 7-mm slice thickness) for acute flank pain during a 5-year period were reviewed. The radiological diagnoses of urinary calculi and obstruction as well as clinical entities not suspected otherwise were analyzed. RESULTS: A total of 4000 CTs had been performed in the evaluation of acute flank pain. Urinary calculi had been identified in 3120 patients (78.0%). There were 398 patients (9.9%) who had an alternate cause of flank pain or an incidentally detected condition on CT. Of these patients, 102 (25.6%) had more than one additional finding. A total of 153 clinical conditions had been identified mimicking flank pain secondary to calculus and obstruction. In 47 patients (1.2%), incidental solid masses had been detected. CONCLUSION: Spiral CT is a valuable technique in the evaluation of acute flank pain with uncertain clinical diagnosis. A wide spectrum of alternate and additional diagnoses including abdominal solid organ tumors and other significant abdominal conditions such as pancreatitis can be established or suggested on spiral CT performed for suspected acute urinary colic.

Predictors of renal outcome in HIV-associated nephropathy.

BACKGROUND: Human immunodeficiency virus (HIV)-associated nephropathy (HIVAN) is an important cause of end-stage renal disease among African American patients. This study was performed to study the epidemiology of HIVAN in a predominantly black African population and the impact of highly active antiretroviral therapy and other factors on the development of end-stage renal disease. METHODS: We retrospectively identified all patients with HIVAN, defined by biopsy or strict clinical criteria, in 8 clinics in the United Kingdom. Baseline renal function, HIV parameters, renal pathological index of chronic damage, and responses to highly active antiretroviral therapy were analyzed, and factors associated with adverse renal outcome were identified. RESULTS: From 1998 through 2004, we studied 16,834 patients, 61 of whom had HIVAN. HIVAN prevalence in black patients was 0.93%, and HIVAN incidence in those without renal disease at baseline was 0.61 per 1000 person-years. After a median of 4.2 years, 34 patients (56%) had developed end-stage renal disease. There were no significant differences in renal function and HIV parameters at baseline, time to initiation of highly active antiretroviral therapy, and rates of HIV RNA suppression between the 20 patients who developed end-stage renal disease >3 months after receiving the HIVAN diagnosis and the 23 patients who maintained stable renal function. However, the index of chronic damage score was significantly higher in those who developed end-stage renal disease (P < .001), and an index of chronic damage score >75 was associated with shorter renal survival (P < .001). CONCLUSIONS: Whereas overall patient survival suggested an important benefit of highly active antiretroviral therapy, no additional renal benefit of early initiation of highly active antiretroviral therapy or viral suppression could be demonstrated in this large cohort of patients with established HIVAN. Severity of chronic kidney damage, as quantified by biopsy, was the strongest predictor of renal outcome.

Perceptions of Pakistani medical students about drugs and alcohol: a questionnaire-based survey.

BACKGROUND: Drug abuse is hazardous and known to be prevalent among young adults, warranting efforts to increase awareness about harmful effects and to change attitudes. This study was conducted to assess the perceptions of a group of medical students from Pakistan, a predominantly Muslim country, regarding four drugs namely heroin, charas, benzodiazepines and alcohol. RESULTS: In total, 174 self-reported questionnaires were received (87% response rate). The most commonly cited reasons for why some students take these drugs were peer pressure (96%), academic stress (90%) and curiosity (88%). The most commonly cited justifiable reason was to go to sleep (34%). According to 77%, living in the college male hostel predisposed one to using these drugs. Sixty percent of students said that the drugs did not improve exam performance, while 54% said they alleviated stress. Seventy-eight percent said they did not intend to ever take drugs in the future. Females and day-scholars were more willing to discourage a friend who took drugs. Morality (78%), religion (76%) and harmful effects of drugs (57%) were the most common deterrents against drug intake. Five suggestions to decrease drug abuse included better counseling facilities (78%) and more recreational facilities (60%). CONCLUSION: Efforts need to be made to increase student awareness regarding effects and side effects of drugs. Our findings suggest that educating students about the adverse effects as well as the moral and religious implications of drug abuse is more likely to have a positive impact than increased policing. Proper student-counseling facilities and healthier avenues for recreation are also required.

Sleep deprivation and its associated factors among general ward patients at a tertiary care hospital in Pakistan.

OBJECTIVE: To estimate the occurrence rate of sleep deprivation and to identify the environmental, staff-related and patient-related factors associated with SD among general ward patients of a tertiary care hospital in Pakistan. METHODS: In a cross-sectional study, a pre-tested questionnaire was administered to 108 patients admitted into the general medical and general surgical wards of Aga Khan University Hospital, Karachi. RESULTS: In all, 50 (46.3%) respondents felt deprived of adequate sleep in the hospital. Worry about illness disturbed the night-time sleep of 47 (43.5%) patients; most of these had SD (70%) (p < 0.001). Other patients' noise disturbed 31.5% of study subjects and a significant majority (68%) of these had SD (p = 0.003). Over 17% of study subjects reported cell phone's ringing as a disturbing factor; more by those with SD (68%) compared to those with no SD (32%); again the difference was significant (p = 0.003). Physical discomfort and presence of cannula were reported as disturbing factors by 41.7% and 28.7% of the study subjects respectively but these were not significantly associated with SD. CONCLUSION: Our study revealed that sleep deprivation occurs commonly among general ward patients in tertiary care setting. Factors found to be associated with SD were amenable to modification to a greater extent.