Bedside Nurses' Perceptions of Effective Nurse-Physician Communication in General Medical Units: A Qualitative Study.

Background There is a dearth of research on successful interventions to improve nurse-physician communication (NPC). An important step is identifying what matters to bedside nurses and their perceptions of effective NPC communications and actions. Methods We conducted three focus groups with a total of 19 medical unit nurses across two hospitals in one academic medical center in the United States. Using a convenience sampling strategy, five to eight nurses voluntarily participated in each focus group. The recording was transcribed verbatim and two independent coders performed coding and resolved any discrepancies in codes. Qualitative content analysis was pursued to identify themes and associated quotes. Results The presence of direct communication between physicians and nurses was identified as the first theme and perceived by nurses as very important. Additional themes related to physician communication and attributes emerged including collegiality and respect (e.g., engaging nurses as partners in patient care), attentiveness and responsiveness (e.g., listening carefully and addressing concerns), and directness and support (e.g., backing nurses up in difficult situations). Effective NPC is further facilitated by organizational structure, relationship development separate from patient care, and consistent/timely use of technology. Conclusions Hospital bedside nurses provided valuable insight into improved physician communication and what attributes contribute to more effective NPC. Most importantly, they emphasized the significance of physicians in supporting them with difficult patients.

Optimizing Discharge Summaries: A Multispecialty, Multicenter Survey of Primary Care Clinicians.

BACKGROUND: Patient care in the United States has become increasingly more fragmented, and the discharge summary serves as a critical tool for transmitting information on a patient's hospital admission to the primary care clinician. Some guidelines regarding how to write discharge summaries exist, but few are focused on prioritizing content that is most important to optimize a patient's transition of care. METHODS: We conducted a national survey across various medical primary care specialties, including trainees and advanced practice providers, to understand the priorities of primary care clinicians. We distributed the survey to 2184 clinicians affiliated with 8 large academic institutions. Our response rate was 21%. RESULTS: Hospital course, discharge diagnoses, medication reconciliation, and follow-up sections were ranked as the most important categories with a 95.5% concordance rate among surveyed institutions. The least important sections were contact numbers for inpatient clinicians, ancillary services, weight-bearing status, and wound care. Similar themes were also identified via consensus review of the free-texted comments, adding that discharge summary style was also important. Other identified barriers to high-quality transition of care are both the limited time primary care clinicians can spend reviewing discharge summaries and lack of adequate communication between hospitalists and the outpatient clinician. CONCLUSIONS: High-yield content should be presented at the beginning of the discharge summary and conveyed in a brief, succinct manner to ensure maximal utility of the document as a transition of care tool.

Developing and Demonstrating the Viability and Availability of the Multilevel Implementation Strategy for Syncope Optimal Care Through Engagement (MISSION) Syncope App: Evidence-Based Clinical Decision Support Tool.

BACKGROUND: Syncope evaluation and management is associated with testing overuse and unnecessary hospitalizations. The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Syncope Guideline aims to standardize clinical practice and reduce unnecessary services. The use of clinical decision support (CDS) tools offers the potential to successfully implement evidence-based clinical guidelines. However, CDS tools that provide an evidence-based differential diagnosis (DDx) of syncope at the point of care are currently lacking. OBJECTIVE: With input from diverse health systems, we developed and demonstrated the viability of a mobile app, the Multilevel Implementation Strategy for Syncope optImal care thrOugh eNgagement (MISSION) Syncope, as a CDS tool for syncope diagnosis and prognosis. METHODS: Development of the app had three main goals: (1) reliable generation of an accurate DDx, (2) incorporation of an evidence-based clinical risk tool for prognosis, and (3) user-based design and technical development. To generate a DDx that incorporated assessment recommendations, we reviewed guidelines and the literature to determine clinical assessment questions (variables) and likelihood ratios (LHRs) for each variable in predicting etiology. The creation and validation of the app diagnosis occurred through an iterative clinician review and application to actual clinical cases. The review of available risk score calculators focused on identifying an easily applied and valid evidence-based clinical risk stratification tool. The review and decision-making factors included characteristics of the original study, clinical variables, and validation studies. App design and development relied on user-centered design principles. We used observations of the emergency department workflow, storyboard demonstration, multiple mock review sessions, and beta-testing to optimize functionality and usability. RESULTS: The MISSION Syncope app is consistent with guideline recommendations on evidence-based practice (EBP), and its user interface (UI) reflects steps in a real-world patient evaluation: assessment, DDx, risk stratification, and recommendations. The app provides flexible clinical decision making, while emphasizing a care continuum; it generates recommendations for diagnosis and prognosis based on user input. The DDx in the app is deemed a pragmatic model that more closely aligns with real-world clinical practice and was validated using actual clinical cases. The beta-testing of the app demonstrated well-accepted functionality and usability of this syncope CDS tool. CONCLUSIONS: The MISSION Syncope app development integrated the current literature and clinical expertise to provide an evidence-based DDx, a prognosis using a validated scoring system, and recommendations based on clinical guidelines. This app demonstrates the importance of using research literature in the development of a CDS tool and applying clinical experience to fill the gaps in available research. It is essential for a successful app to be deliberate in pursuing a practical clinical model instead of striving for a perfect mathematical model, given available published evidence. This hybrid methodology can be applied to similar CDS tool development.

Identifying Guideline-Practice Gaps to Optimize Evaluation and Management for Patients With Syncope.

Syncope is a common and complex symptom that requires efficient evaluation to determine the cause. Recent guidelines focus on high-value testing, but a systematic evaluation of their implementation has not been performed. To this end, we used a mixed-methods approach of surveys, chart reviews, and focus groups to understand current practices relating to the diagnosis and management of patients with syncope and to identify barriers and facilitators to the implementation of guideline-supported recommendations. Surveys were distributed to 1500 providers in the specialties of hospital medicine, cardiology, emergency medicine, and family medicine, and 175 responses were received. Knowledge of class I and III guideline recommendations were assessed with the use of clinical vignettes, which were answered correctly 60%-80% of the time. Chart reviews focused on patient history and testing for syncope. Per the guidelines, < 50% of charts met criteria for bare minimum history and physical examination. Based on the documentation, 25% of echocardiograms and 90% of neurologic testing obtained would not have been appropriate per the guidelines. Self-reported and actual practice patterns were similar in rates of testing. Our results indicate that there remains a gap between guideline-directed management and actual practice for syncope. Focus groups revealed barriers across multiple levels of care that need to be addressed to improve care. Our findings emphasize the need for proactive strategies to improve syncope testing practices, potentially saving millions of dollars in the health care system.

Value-based syncope evaluation and management: Perspectives of health care professionals on readiness, barriers and enablers.

BACKGROUND: Syncope is a common condition seen in the emergency department. Given the multitude of etiologies, research exists on the evaluation and management of syncope. Yet, physicians' approach to patients with syncope is variable and often not value based. The 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with Syncope includes a focus on unnecessary medical testing. However, little research assesses implementation of the guidelines. METHODS: Mixed methods approach was applied. The targeted provider specialties include emergency medicine, hospital medicine and cardiology. The Evidence-based Practice Attitude Scale-36 and the Organizational Readiness to Change Assessment surveys were distributed to four different hospital sites. We then conducted focus groups and key informant interviews to obtain more information about clinicians' perceptions to guideline-based practice and barriers/facilitators to implementation. Descriptive statistics and bivariate analyses were used for survey analysis. Two-stage coding was used to identify themes with NVivo. RESULTS: Analysis of surveys revealed that overall attitude toward evidence-based practices was moderate and implementation of new guidelines were seen as a burden, potentially decreasing compliance. There were differences across hospital settings. Five common themes emerged from interviews: uncertainty of a syncope diagnosis, rise of consumerism in health care, communication challenge with patient, provider differences in standardized care, and organizational processes to change. CONCLUSIONS: Despite recommendations for the use of syncope guidelines, adherence is suboptimal. Overcoming barriers to use will require a paradigm shift. A multifaceted approach and collaborative relationships are needed to adhere to the Guidelines to improve patient care and operational efficiency.

Letter to the Editor, What Can Be Done to Maintain Positive Patient Experience and Improve Residents' Satisfaction? In Reference to: "Standardized Attending Rounds to Improve the Patient Experience: A Pragmatic Cluster Randomized Controlled Trial".

We read the article by Monash et al. published in the March 2017 issue with great interest. This randomized study showed a discrepancy between patients' and residents' satisfaction with standardized rounds; for example, residents reported less autonomy, efficiency, teaching, and longer time of rounds.

The Role of Sodium Bicarbonate in the Management of Some Toxic Ingestions.

Adverse reactions to commonly prescribed medications and to substances of abuse may result in severe toxicity associated with increased morbidity and mortality. According to the Center for Disease Control, in 2013, at least 2113 human fatalities attributed to poisonings occurred in the United States of America. In this article, we review the data regarding the impact of systemic sodium bicarbonate administration in the management of certain poisonings including sodium channel blocker toxicities, salicylate overdose, and ingestion of some toxic alcohols and in various pharmacological toxicities. Based on the available literature and empiric experience, the administration of sodium bicarbonate appears to be beneficial in the management of a patient with the above-mentioned toxidromes. However, most of the available evidence originates from case reports, case series, and expert consensus recommendations. The potential mechanisms of sodium bicarbonate include high sodium load and the development of metabolic alkalosis with resultant decreased tissue penetration of the toxic substance with subsequent increased urinary excretion. While receiving sodium bicarbonate, patients must be monitored for the development of associated side effects including electrolyte abnormalities, the progression of metabolic alkalosis, volume overload, worsening respiratory status, and/or worsening metabolic acidosis. Patients with oliguric/anuric renal failure and advanced decompensated heart failure should not receive sodium bicarbonate.

Dye-free wire-guided cannulation of the biliary tree during ERCP is associated with high success and low complication rates: outcomes in a single operator experience of 822 cases.

BACKGROUND: Deep biliary cannulation (DBC) is a prerequisite to most endoscopic retrograde cholangiopancreatographies (ERCPs). Numerous techniques have been described to maximize success and minimize ERCP-related complications, most notably post-ERCP pancreatitis. Dye-free cannulation by using guidewires with hydrophilic tips has been proposed as a technique with a high rate of success and a low rate of complications. We report the outcomes 822 consecutive ERCP procedures by using dye-free guidewire cannulation techniques. OBJECTIVE: To evaluate the success rate for DBC and rates of complications by using dye-free guidewire cannulation techniques. DESIGN: Retrospective. Consecutive ERCP procedures with intent to achieve DBC exclusively by using dye-free guidewire technique were included. Complication data on post-ERCP pancreatitis, bleeding, perforation, and cholangitis were extracted. SETTING: University. PATIENTS: Patients undergoing biliary ERCP. INTERVENTIONS: ERCP. MAIN OUTCOME MEASUREMENTS: Success, complication rates. RESULTS: Eight hundred and twenty-two ERCPs were performed on 744 patients. Five hundred and fifty-nine (68%) procedures were performed on inpatients, 263 (32%) on outpatients. DBC was successful in 801 of 822 (97%) ERCPs. In 795 of 801 (99%) ERCPs with successful DBC procedures, DBC was achieved in a dye-free fashion. Eleven patients (1.3%) developed post-ERCP pancreatitis-all cases were mild. Guidewire perforations occurred 11 times (1.3%), none required surgery. Ten of 11 patients with known or suspected (91%) guidewire perforation achieved successful DBC on repeat ERCP by the same endoscopist by using dye-free techniques. LIMITATIONS: Retrospective. CONCLUSIONS: In this large retrospective case series, a high success rate of DBC was achieved by using dye-free guidewire techniques. This technique has associated lower rates of complications in comparison to those reported earlier.

Phase II trial of the combination of bevacizumab and erlotinib in patients who have advanced hepatocellular carcinoma.

PURPOSE: The study objective was to determine the proportion of patients with hepatocellular carcinoma (HCC) treated with the combination of bevacizumab (B) and erlotinib (E) who were alive and progression free at 16 weeks (16-week progression-free survival [PFS16]) of continuous therapy. Secondary objectives included response rate, median PFS, survival, and toxicity. PATIENTS AND METHODS: Patients who had advanced HCC that was not amenable to surgical or regional therapies, up to one prior systemic treatment; Childs-Pugh score A or B liver function; Eastern Cooperative Oncology Group performance status 0, 1, or 2 received B 10 mg/kg every 14 days and E 150 mg orally daily, continuously, for 28-day cycles. Tumor response was evaluated every 2 cycles by using Response Evaluation Criteria in Solid Tumors Group criteria. A total of 40 patients were treated. RESULTS: The primary end point of PFS16 was 62.5%. Ten patients achieved a partial response for a confirmed overall response rate (intent-to-treat) of 25%. The median PFSevent was 39 weeks (95% CI, 26 to 45 weeks; 9.0 months), and the median overall survival was 68 weeks (95% CI, 48 to 78 weeks; 15.65 months). Grades 3 to 4 drug-related toxicity included fatigue (n = 8; 20%), hypertension (n = 6; 15%), diarrhea (n = 4; 10%) elevated transaminases (n = 4; 10%), gastrointestinal hemorrhage (n = 5; 12.5%), wound infection (n = 2; 5%) thrombocytopenia (n = 1; 2.5%), and proteinuria, hyperbilirubinemia, back pain, hyperkalemia, and anorexia (n = 1 each). CONCLUSION: The combination of B + E in patients who had advanced HCC showed significant, clinically meaningful antitumor activity. B + E warrant additional evaluation in randomized controlled trials.

Second-line chemotherapy use in metastatic colon cancer varies by disease responsiveness.

BACKGROUND: Improved survival of patients with metastatic colorectal cancer (CRC) has been shown to correlate with increased utilization of the 3 active cytotoxic chemotherapeutic agents: 5-fluorouracil (5-FU), irinotecan, and oxaliplatin, usually administered in 2 lines of therapy. However, it is unclear which patient, disease, and treatment characteristics are associated with the utilization of a second-line regimen. PATIENTS AND METHODS: We performed a retrospective chart review. Patients with metastatic CRC treated with bevacizumab outside of a clinical trial and any infusional 5-FU/leucovorin (LV) regimen off-protocol (ie, 5-FU/LV/irinotecan [FOLFIRI]/bevacizumab or 5-FU/LV/oxaliplatin [FOLFOX]/bevacizumab) at the University of Texas M. D. Anderson Cancer Center between February 2004 and September 2005 were included. Prespecified characteristics of age, tumor burden, severe toxicity, and front-line regimen efficacy were compared with exploratory analyses of additional patient, disease, and treatment characteristics. RESULTS: Eighty-seven sequential patients treated with the specified front-line regimens were identified. Seventy-six percent of the eligible patients were treated with a second-line regimen. Despite equal treatment durations, patients with a better response of stable disease were significantly less likely to receive a third cytotoxic agent than patients with a partial response (68% vs. 95%; odds ratio, 8.2; P = .02) due to declining performance status (86%) or patient preference (14%). This was associated with a decreased 2-year overall survival (86% vs. 55%). Neither age, tumor burden, nor development of toxicities were associated with a different utilization of a second-line regimen. CONCLUSION: Failure to obtain a response to initial chemotherapy for metastatic disease appears to be associated with decreased utilization of a second-line regimen.

Phase 2 study of erlotinib in patients with unresectable hepatocellular carcinoma.

BACKGROUND: Growth factor overexpression, including epidermal growth factor receptor (EGFR) expression, is common in hepatocellular cancers. Erlotinib is a receptor tyrosine kinase inhibitor with specificity for EGFR. The primary objective of this study was to determine the proportion of hepatocellular carcinoma (HCC) patients treated with erlotinib who were alive and progression-free (PFS) at 16 weeks of continuous treatment. METHODS: Patients with unresectable HCC, no prior systemic therapy, performance status (PS) of 0, 1, or 2, and Childs-Pugh (CP) cirrhosis A or B received oral erlotinib 150 mg daily for 28-day cycles. Tumor response was assessed every 2 cycles by using Response Evaluation Criteria in Solid Tumors (RECIST; National Cancer Institute Cancer Therapy Evaluation Program, Bethesda, Md) criteria. Patients accrued to either "low" or "high" EGFR expression cohorts; each cohort had stopping rules applied when there was a lack of efficacy. RESULTS: Forty HCC patients were enrolled. Median age was 64 years (range, 33-83 years), sex distribution was 32 males and 8 females, performance scores were 40% PS 0, 55% PS 1, Childs-Pugh distribution was 75% A and 20% B. There were no complete or partial responses; however, 17 of 40 patients achieved stable disease at 16 weeks of continuous therapy. The PFS at 16 weeks was 43%, and the median overall survival (OS) was 43 weeks (10.75 months). No patients required dose reductions of erlotinib. No correlation between EGFR expression and outcome was found. CONCLUSIONS: Results of this study indicated that single-agent erlotinib is well tolerated and has modest disease-control benefit in HCC, manifested as modestly prolonged PFS and OS when compared with historical controls.