eConsultation for Deprescribing Among Older Adults: Clinician Perspectives on Implementation Barriers and Facilitators.

BACKGROUND: Electronic consultations (eConsults) enable asynchronous consultation between primary care providers (PCPs) and specialists. eConsults have been used successfully to manage a variety of conditions and have the potential to help PCPs manage polypharmacy and promote deprescribing. OBJECTIVE: To elicit clinician perspectives on barriers/facilitators of using eConsults for deprescribing among older adults within a university health network. DESIGN: Semi-structured interviews. PARTICIPANTS: PCPs, geriatricians, and pharmacists. APPROACH: We used the COM-B (Capability, Opportunity, Motivation, and Behavior) model to structure the interview guide and qualitative analysis methods to identify barriers/facilitators of (1) deprescribing and (2) use of eConsults for deprescribing. KEY RESULTS: Of 28 participants, 19 were PCPs (13 physicians, 4 residents, 2 nurse practitioners), 7 were geriatricians, and 2 were pharmacists. Barriers and facilitators to deprescribing: PCPs considered deprescribing important but identified myriad barriers (e.g., time constraints, fragmented clinical care, lack of pharmacist integration, and patient/family resistance). Use of eConsults for deprescribing: Both PCPs and geriatricians highlighted the limits of contextual information available through electronic health record (vs. face-to-face) to render specific and actionable eConsults (e.g., knowledge of prior deprescribing attempts). Participants from all groups expressed interest in a targeted process whereby eConsults could be offered for select patients based on key factors (e.g., polypharmacy or certain comorbidities) and accepted or declined by PCPs, with pithy recommendations delivered in a timely manner relative to patient appointments. This was encapsulated by one PCP: "they need to be crisp and to the point to be helpful, with specific suggestions of something that could be discontinued or switched…not, 'hey, did you know your patient is on over 12 medicines?'". CONCLUSIONS: Clinicians identified multifaceted factors influencing the utility of eConsults for deprescribing among older adults in primary care. Deprescribing eConsult interventions should be timely, actionable, and mindful of limitations of electronic chart review.

Accuracy of Patient-Collected Vital Signs.

Introduction: Telehealth has emerged as an important clinical setting for managing acute respiratory tract infections (ARIs), potentially reducing emergency department and urgent care overcrowding, and reducing nosocomial transmission. Many current algorithms for ARI management incorporate information on patient vital signs. However, the accuracy of vital signs collected by patients using readily available home devices and techniques has not been studied. Methods: A cross-sectional sample of patients seen for urgent conditions at a hospital emergency and urgent care center were given instructions and low-cost, readily available devices to collect their vital signs. A trained research coordinator collected a parallel set of vital signs using standard hospital equipment, serving as the gold standard. We analyzed the performance of patient-collected vital signs compared with vital signs collected by a trained research coordinator. Results: A total of 300 patients completed the study. Patient-collected vital signs were highly specific for traditional levels of abnormalities (HR >100 beats per min, RR >24 breaths per min, temperature >100.4 degrees Fahrenheit, oxygen saturation <94 percent); however, sensitivity was poor for elevated heart rate by pulse estimation (25%) and elevated respiratory rate (60%). Heart rate and oxygen saturation by pulse oximeter and oral temperature had higher sensitivity. Conclusions: Vital signs measured and provided by patients are not uniformly accurate, particularly when using manual techniques rather than automated devices. Telehealth algorithms that rely on these values could provide incorrect triage and management advice.

Secondary Cases of Delta Variant Coronavirus Disease 2019 Among Vaccinated Healthcare Workers With Breakthrough Infections is Rare.

In a retrospective, cohort study at 4 medical centers with high coronavirus disease 2019 vaccination rates, we evaluated breakthrough severe acute respiratory syndrome coronavirus 2 Delta variant infections in vaccinated healthcare workers. Few work-related secondary cases were identified. Breakthrough cases were largely due to unmasked social activities outside of work.

Molecular dynamics study on the elucidation of polyamide membrane fouling by nonionic surfactants and disaccharides.

Reverse osmosis (RO) is a widely used energy-efficient separation technology for water treatment. Polyamide (PA) membranes are the conventional choice for this process. Fouling is a serious problem for RO separation. This issue leads to significant decreases in the water permeability of PA membranes, and it has yet to be fully elucidated. In particular, the fouling behavior of a nonionic substance on the negatively charged surface of a PA membrane in an aqueous environment has not been previously studied. In this work, the mechanisms of nonionic substances such as polyoxyethylene octyl ether (PE5) and maltose (Mal) were investigated using molecular dynamics (MD) simulations. In a PA membrane in which the carboxyl group was not dissociated, the hydrophobic portion of the membrane was exposed due to the localization of water molecules around the carboxyl groups in the PA membrane. This caused hydrophobic interaction with the hydrophobic groups of PE5. In the case of an amine-modified PA membrane containing no carboxyl groups, water was not localized around the functional group, and the water orientation of the polyamide surface was also low. Due to this membrane property, the presence of stabilized water around PE5 reduced the number of hydrophobic interactions. In similar manner, a PA membrane with a slightly dissociated carboxyl group was hydrophilic, which reduced the PE5 adsorption. The presence of many dissociated carboxyl groups, however, enhanced the adsorption of PE5 due to the increase in interactions between the dissociated carboxyl groups and the hydrophilic groups of PE5. Therefore, PE5 exhibited an amphipathic adsorption wherein both hydrophilic and hydrophobic groups contributed to adsorption onto the PA membrane. Mal, on the other hand, was highly stable in every aqueous environment independent of the state of the functional groups of the PA membrane, and was not easily affected by the properties of the PA membrane.

Randomized Controlled Trials of Electronic Health Record Interventions: Design, Conduct, and Reporting Considerations.

Electronic health record (EHR) systems can be configured to deliver novel EHR interventions that influence clinical decision making and to support efficient randomized controlled trials (RCTs) designed to evaluate the effectiveness, safety, and costs of those interventions. In designing RCTs of EHR interventions, one should carefully consider the unit of randomization (for example, patient, encounter, clinician, or clinical unit), balancing concerns about contamination of an intervention across randomization units within clusters (for example, patients within clinical units) against the superior control of measured and unmeasured confounders that comes with randomizing a larger number of units. One should also consider whether the key computational assessment components of the EHR intervention, such as a predictive algorithm used to target a subgroup for decision support, should occur before randomization (so that only 1 subgroup is randomized) or after randomization (including all subgroups). When these components are applied after randomization, one must consider expected heterogeneity in the effect of the differential decision support across subgroups, which has implications for overall impact potential, analytic approach, and sample size planning. Trials of EHR interventions should be reviewed by an institutional review board, but may not require patient-level informed consent when the interventions being tested can be considered minimal risk or quality improvement, and when clinical decision making is supported, rather than controlled, by an EHR intervention. Data and safety monitoring for RCTs of EHR interventions should be conducted to guide institutional pragmatic decision making about implementation and ensure that continuing randomization remains justified. Reporting should follow the CONSORT (Consolidated Standards of Reporting Trials) Statement, with extensions for pragmatic trials and cluster RCTs when applicable, and should include detailed materials to enhance reproducibility.

A Comparison of Patient-Reported Outcomes Related to Telephone Follow-Up Visits and Conventional Office Visits in Medical Specialty Practices.

Background/Introduction: Scheduled telephone follow-up visits (TFVs) are one strategy for improving access to specialty care practices, primarily because TFVs can be completed in less time with lower overhead costs than conventional office-based follow-up visits (OFVs). Beginning January 2015, scheduled TFVs were introduced in three specialty care practices at University of California San Francisco (UCSF) as a substitute for scheduled OFVs. As there is limited data on the relative advantage to patients from such a program, we conducted a survey to evaluate patient-reported outcomes associated with both TFVs and OFVs. Materials and Methods: All patients who completed a follow-up visit in Endocrinology, Hepatology, or Multiple Sclerosis clinics between March and May 2016 were surveyed. Primary outcomes included out-of-pocket costs associated with follow-up visits, visit duration, and satisfaction. Responses were analyzed using univariate and bivariate statistics, and both t-tests and chi-square tests were employed to determine significance. Results: A total of 2,741 patients were surveyed, of which 16% (n = 432) responded. Median self-reported costs associated with OFVs, including travel was $50 (interquartile range [IQR]: 20,100), and median visit duration was 240 (IQR: 150; 420) minutes. Of all TFV respondents, only one reported a cost of $15, and 99% of TFV respondents reported being satisfied with their TFV experience. Discussion/Conclusion: At UCSF, TFVs offer an efficient alternative to office-based visits in a manner that is both acceptable and affordable to patients. This study fills an important gap in understanding the patient's perception of telephone follow-up care, and represents a critical first step in mobilizing health plans to pay for TFVs.

Healthcare Provider Perceptions of Cardiopulmonary Resuscitation Quality During Simulation Training.

OBJECTIVES: To assess the relationship between quantitative and perceived cardiopulmonary resuscitation performance when healthcare providers have access to and familiarity with audiovisual feedback devices. DESIGN: Prospective observational study. SETTING: In situ simulation events throughout a pediatric quaternary care center where the use of continuous audiovisual feedback devices during cardiopulmonary resuscitation is standard. SUBJECTS: Healthcare providers who serve as first responders to in-hospital cardiopulmonary arrest. INTERVENTIONS: High-fidelity simulation of resuscitation with continuous audiovisual feedback. MEASUREMENTS AND MAIN RESULTS: Objective data was collected using accelerometer-based measurements from a cardiopulmonary resuscitation defibrillator/monitor. After the simulation event but before any debriefing, participants completed self-evaluation forms to assess whether they believed the cardiopulmonary resuscitation performed met the American Heart Association guidelines for chest compression rate, chest compression depth, chest compression fraction, chest compression in target, and duration of preshock pause and postshock pause. An association coefficient (kappa) was calculated to determine degree of agreement between perceived performance and the quantitative performance data that was collected from the CPR defibrillator/monitor. Data from 27 mock codes and 236 participants was analyzed. Average cardiopulmonary resuscitation performance was chest compression rate 106 ± 10 compressions per minute; chest compression depth 2.05 ± 0.6 in; chest compression fraction 74% ± 10%; chest compression in target 22% ± 21%; preshock pause 8.6 ± 7.2 seconds; and postshock pause 6.4 ± 8.9 seconds. When all healthcare providers were analyzed, the association coefficient (κ) for chest compression rate (κ = 0.078), chest compression depth (κ = 0.092), chest compression fraction (κ = 0.004), preshock pause (κ = 0.321), and postshock pause (κ = 0.40) was low, with no variable achieving moderate agreement (κ > 0.4). CONCLUSIONS: Cardiopulmonary resuscitation performance during mock codes does not meet the American Heart Association's quality recommendations. Healthcare providers have poor insight into the quality of cardiopulmonary resuscitation during mock codes despite access to and familiarity with continuous audiovisual feedback.

The added value of C-reactive protein measurement in diagnosing pneumonia in primary care: a meta-analysis of individual patient data.

BACKGROUND: C-reactive protein (CRP) is increasingly being included in the diagnostic work-up for community-acquired pneumonia in primary care. Its added diagnostic value beyond signs and symptoms, however, remains unclear. We conducted a meta-analysis of individual patient data to quantify the added value of CRP measurement. METHODS: We included studies of the diagnostic accuracy of CRP in adult outpatients with suspected lower respiratory tract infection. We contacted authors of eligible studies for inclusion of data and for additional data as needed. The value of adding CRP measurement to a basic signs-and-symptoms prediction model was assessed. Outcome measures were improvement in discrimination between patients with and without pneumonia in primary care and improvement in risk classification, both within the individual studies and across studies. RESULTS: Authors of 8 eligible studies (n = 5308) provided their data sets. In all of the data sets, discrimination between patients with and without pneumonia improved after CRP measurement was added to the prediction model (extended model), with a mean improvement in the area under the curve of 0.075 (range 0.02-0.18). In a hypothetical cohort of 1000 patients, the proportion of patients without pneumonia correctly classified at low risk increased from 28% to 36% in the extended model, and the proportion with pneumonia correctly classified at high risk increased from 63% to 70%. The number of patients with pneumonia classified at low risk did not change (n = 4). Overall, the proportion of patients assigned to the intermediate-risk category decreased from 56% to 51%. INTERPRETATION: Adding CRP measurement to the diagnostic work-up for suspected pneumonia in primary care improved the discrimination and risk classification of patients. However, it still left a substantial group of patients classified at intermediate risk, in which clinical decision-making remains challenging.

Relationship Between a Sepsis Intervention Bundle and In-Hospital Mortality Among Hospitalized Patients: A Retrospective Analysis of Real-World Data.

BACKGROUND: Sepsis is a systemic response to infection that can lead to tissue damage, organ failure, and death. Efforts have been made to develop evidence-based intervention bundles to identify and manage sepsis early in the course of the disease to decrease sepsis-related morbidity and mortality. We evaluated the relationship between a minimally invasive sepsis intervention bundle and in-hospital mortality using robust methods for observational data. METHODS: We performed a retrospective cohort study at the University of California, San Francisco, Medical Center among adult patients discharged between January 1, 2012, and December 31, 2014, and who received a diagnosis of severe sepsis/septic shock (SS/SS). Sepsis intervention bundle elements included measurement of blood lactate; drawing of blood cultures before starting antibiotics; initiation of broad spectrum antibiotics within 3 hours of sepsis presentation in the emergency department or 1 hour of presentation on an inpatient unit; administration of intravenous fluid bolus if the patient was hypotensive or had a lactate level >4 mmol/L; and starting intravenous vasopressors if the patient remained hypotensive after fluid bolus administration. Poisson regression for a binary outcome variable was used to estimate an adjusted incidence-rate ratio (IRR) comparing mortality in groups defined by bundle compliance measured as a binary predictor, and to estimate an adjusted number needed to treat (NNT). RESULTS: Complete bundle compliance was associated with a 31% lower risk of mortality (adjusted IRR, 0.69, 95% confidence interval [CI], 0.53-0.91), adjusting for SS/SS presentation in the emergency department, SS/SS present on admission (POA), age, admission severity of illness and risk of mortality, Medicaid/Medicare payor status, immunocompromised host status, and congestive heart failure POA. The adjusted NNT to save one life was 15 (CI, 8-69). Other factors independently associated with mortality included SS/SS POA (adjusted IRR, 0.55; CI, 0.32-0.92) and increased age (adjusted IRR, 1.13 per 10-year increase in age; CI, 1.03-1.24). CONCLUSIONS: The University of California, San Francisco, sepsis bundle was associated with a decreased risk of in-hospital mortality across hospital units after robust control for confounders and risk adjustment. The adjusted NNT provides a reasonable and achievable goal to observe measureable improvements in outcomes for patients diagnosed with SS/SS.

The Action Research Program: Experiential Learning in Systems-Based Practice for First-Year Medical Students.

PROBLEM: Systems-based practice focuses on the organization, financing, and delivery of medical services. The American Association of Medical Colleges has recommended that systems-based practice be incorporated into medical schools' curricula. However, experiential learning in systems-based practice, including practical strategies to improve the quality and efficiency of clinical care, is often absent from or inconsistently included in medical education. INTERVENTION: A multidisciplinary clinician and nonclinician faculty team partnered with a cardiology outpatient clinic to design a 9-month clerkship for 1st-year medical students focused on systems-based practice, delivery of clinical care, and strategies to improve the quality and efficiency of clinical operations. The clerkship was called the Action Research Program. In 2013-2014, 8 trainees participated in educational seminars, research activities, and 9-week clinic rotations. A qualitative process and outcome evaluation drew on interviews with students, clinic staff, and supervising physicians, as well as students' detailed field notes. CONTEXT: The Action Research Program was developed and implemented at the University of California, San Francisco, an academic medical center in the United States. All educational activities took place at the university's medical school and at the medical center's cardiology outpatient clinic. OUTCOME: Students reported and demonstrated increased understanding of how care delivery systems work, improved clinical skills, growing confidence in interactions with patients, and appreciation for patients' experiences. Clinicians reported increased efficiency at the clinic level and improved performance and job satisfaction among medical assistants as a result of their unprecedented mentoring role with students. Some clinicians felt burdened when students shadowed them and asked questions during interactions with patients. Most student-led improvement projects were not fully implemented. LESSONS LEARNED: The Action Research Program is a small pilot project that demonstrates an innovative pairing of experiential and didactic training in systems-based practice. Lessons learned include the need for dedicated time and faculty support for students' improvement projects, which were the least successful aspect of the program. We recommend that future projects aiming to combine clinical training and quality improvement projects designate distinct blocks of time for trainees to pursue each of these activities independently. In 2014-2015, the University of California, San Francisco School of Medicine incorporated key features of the Action Research Program into the standard curriculum, with plans to build upon this foundation in future curricular innovations.

High Rate of Hospital Admissions Among Patients with Cirrhosis Seeking Care in US Emergency Departments.

BACKGROUND AND AIMS: Emergency Departments (ED) can serve as a gateway to specialty care for patients with cirrhosis with limited care access. We described the rates and characteristics of patients with cirrhosis who access United States (US) EDs, and identified factors associated with subsequent hospitalization. METHODS: Using data from the National Hospital Ambulatory Medical Care Survey, cirrhosis-related ED from 2000 to 2009 were identified and compared to all other ED visits. RESULTS: From 2000 to 2009, there were an estimated 1,029,693 cirrhosis and 877 million non-cirrhosis visits. Compared to the general ED population, those with cirrhosis were more frequently male (58 vs. 44 %, p = 0.02), Hispanic (18.6 vs. 10.6 %, p < 0.05), seeking care in urban areas (91.6 vs. 73.4 %, p < 0.05) and had Medicaid/no insurance (43 vs. 35 %, p < 0.01). Patients with cirrhosis were more frequently triaged immediately or emergently (72.3 vs. 54.2 %, p < 0.01). The majority were admitted or transferred to another hospital (66.8 vs. 17.4 %, p < 0.01). Among patients with cirrhosis, patients with age ≥ 65 years were more likely to be admitted (adjusted OR 2.49, 95 % CI 1.08-5.73), and Medicaid/uninsured (adjusted OR 0.34; 95 % CI 0.17-0.67) were less likely to be admitted, after adjusting for patient demographics, hospital characteristics, and triage score. CONCLUSIONS: Patient with cirrhosis account for approximately 100,000 US ED visits annually. The higher admission rates among patients with cirrhosis indicate a high acuity of illness. Older age among those admitted may reflect poorer functional status. Finally, high visit but low admission rates among those with Medicaid/no insurance suggest a gap in specialty care.

Transforming the endocrine consult: asynchronous provider consultations.

OBJECTIVE: To analyze the impact of virtual consultations on the spectrum and volume of endocrine consults, access to endocrine care, and downstream healthcare utilization. METHODS: A program (eConsults) designed to enable and reimburse asynchronous consultations between primary care physicians (PCPs) and specialists at the University of California, San Francisco, was launched in 2012. All eConsults (n = 158) submitted to endocrinology over the first year were analyzed for clinical focus and use of structured referral templates. PCP compliance with specialist recommendations was measured and stratified by provider type. Impact on endocrine referral volume was calculated using simple linear regression. Changes in wait times to endocrine care were analyzed comparing administrative data from the year of and the year prior to the introduction of eConsults. Downstream endocrine office visits, emergency department visits, and hospitalizations were captured by chart abstraction for all standard endocrine eConsults (n = 113). RESULTS: The proportion of endocrine referrals sent as eConsults (15 to 22%) was significantly higher than the combined average for all other participating specialties (7.4%) (P<.001). Overall, 76.0% of endocrinologist recommendations were fully implemented. There was no induced demand in total volume of referrals to endocrinology, and introduction of eConsults significantly improved access to endocrine care (odds ratio, 3.6; 95% confidence interval, 2.7 to 4.9). Rates of downstream healthcare utilization within 6 months of a completed eConsult were low. CONCLUSION: Use of virtual consultations in a fee-for-service, academic medical center setting significantly improved access to endocrine care and the quality of referrals. Increasing recognition and reimbursement of nontraditional consultation models will be essential to scaling and disseminating these programs.

Predicting cost of care using self-reported health status data.

BACKGROUND: We examined whether self-reported employee health status data can improve the performance of administrative data-based models for predicting future high health costs, and develop a predictive model for predicting new high cost individuals. METHODS: This retrospective cohort study used data from 8,917 Safeway employees self-insured by Safeway during 2008 and 2009. We created models using step-wise multivariable logistic regression starting with health services use data, then socio-demographic data, and finally adding the self-reported health status data to the model. RESULTS: Adding self-reported health data to the baseline model that included only administrative data (health services use and demographic variables; c-statistic = 0.63) increased the model" predictive power (c-statistic = 0.70). Risk factors associated with being a new high cost individual in 2009 were: 1) had one or more ED visits in 2008 (adjusted OR: 1.87, 95 % CI: 1.52, 2.30), 2) had one or more hospitalizations in 2008 (adjusted OR: 1.95, 95 % CI: 1.38, 2.77), 3) being female (adjusted OR: 1.34, 95 % CI: 1.16, 1.55), 4) increasing age (compared with age 18-35, adjusted OR for 36-49 years: 1.28; 95 % CI: 1.03, 1.60; adjusted OR for 50-64 years: 1.92, 95 % CI: 1.55, 2.39; adjusted OR for 65+ years: 3.75, 95 % CI: 2.67, 2.23), 5) the presence of self-reported depression (adjusted OR: 1.53, 95 % CI: 1.29, 1.81), 6) chronic pain (adjusted OR: 2.22, 95 % CI: 1.81, 2.72), 7) diabetes (adjusted OR: 1.73, 95 % CI: 1.35, 2.23), 8) high blood pressure (adjusted OR: 1.42, 95 % CI: 1.21, 1.67), and 9) above average BMI (adjusted OR: 1.20, 95 % CI: 1.04, 1.38). DISCUSSION: The comparison of the models between the full sample and the sample without theprevious high cost members indicated significant differences in the predictors. This has importantimplications for models using only the health service use (administrative data) given that the past high costis significantly correlated with future high cost and often drive the predictive models. CONCLUSIONS: Self-reported health data improved the ability of our model to identify individuals at risk for being high cost beyond what was possible with administrative data alone.

When to repatriate? Clinicians' perspectives on the transfer of patient management from specialty to primary care.

BACKGROUND: Subspecialty ambulatory care visits have doubled in the past 10 years and nearly half of all visits are for follow-up care. Could some of this care be provided by primary care providers (PCPs)? OBJECTIVE: To determine how often PCPs and specialists agree that a mutual patient's condition could be managed exclusively by the PCP, and to understand PCPs' perspectives on factors that influence decisions about 'repatriation,' or the transfer of patient management to primary care. DESIGN: A mixed method approach including paired surveys of PCPs and specialists about the necessity for ongoing specialty care of mutual patients, and interviews with PCPs about care coordination practices and reasons for differing opinions with specialists. PARTICIPANTS: One hundred and eighty-nine PCPs and 59 physicians representing five medicine subspecialties completed paired surveys for 343 patients. Semi-structured interviews were conducted with 16 PCPs. MEASUREMENTS: For each patient, PCPs and specialists were asked, "Could this diagnosis be managed exclusively by the PCP?" RESULTS: Specialists and PCPs agreed that transfer to primary care was appropriate for 16% of patients, whereas 36% had specialists and PCPs who agreed that ongoing specialty care was appropriate. Specialists were half as likely as PCPs to identify patients as appropriate for transfer to primary care. PCPs identified several factors that influence the likelihood that patients will be transferred to primary care, including perceived patient preferences, limited access to physician appointments, excessive workload, inter-clinician communication norms, and differences in clinical judgment. We group these factors into two domains: 'push-back' and 'pull-back' to primary care. CONCLUSIONS: At a large academic medical center, approximately one in six patients receiving ongoing specialty care could potentially be managed exclusively by a PCP. PCPs identified several non-clinical factors to explain continuation of specialty care when patient transfer to PCP is clinically appropriate.

Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.

BACKGROUND: After hospital discharge, patients are at risk for medication errors, missed test results, adverse events, and readmissions. Handoff communication between the inpatient and outpatient settings is primarily accomplished with the discharge summary. However, critical information can often be missing, such as the date of the first postdischarge follow-up visit, a complete and accurate list of discharge medications, and follow-up recommendations. There have been no studies focusing on identifying and implementing a parsimonious, clinically relevant, inpatient-to-outpatient discharge handoff tool within a fully integrated electronic medical record (EMR) system. A concise, written, electronic handoff communication tool was created to address this gap. METHODS: Using inpatient and outpatient provider stakeholder input, a standard, succinct, and clinically relevant handoff tool was designed and implemented within the Veterans Affairs EMR. Retrospective chart review at 3 and 15 months after the handoff tool rollout in December 2010 was conducted to monitor handoff uptake and outcomes. RESULTS: At 15 months after implementation, 86% (129/150) of patients had a completed handoff at the time of discharge. More handoff notes were available in the EMR within 24 hours of discharge than discharge summaries (100% versus 77%, p < .0001). There was no difference between those patients with or without a handoff in the number of emergency department visits or readmissions. DISCUSSION: A standardized clinically relevant discharge handoff tool had high user uptake and sustainability and improved timeliness of communication of information between the hospital and outpatient setting. Even within a fully integrated EMR system, simple and efficient handoffs between inpatient and outpatient providers may fulfill a communication gap at the time of discharge.

Emergency department visits in the neonatal period in the United States.

OBJECTIVES: This study aimed to estimate the incidence of emergency department (ED) visits in the neonatal period in a nationally representative sample and to examine variation by race. METHODS: The National Hospital Ambulatory Medical Care Survey is a nationally representative survey of utilization of ambulatory care services including EDs. We studied all ED visits for patients who were younger than 28 days old from 2003 to 2008. Using the national birth certificate data, we calculated the visit rates by race. Emergency department visits were also characterized by age, insurance status, diagnosis category, region, and hospital type (safety-net vs non-safety-net hospitals). RESULTS: There was an average of 320,540 neonatal ED visits in the United States per year, with an estimated 7.6% of births visiting the ED within 28 days. Estimated rates of ED visits were highest among non-Hispanic blacks, with 14.4% (95% confidence interval [CI], 10.0-19.2) of newborns having an ED visit in the neonatal period, compared with 6.7% (95% CI, 4.9-7.2) for whites and 7.7% (95% CI, 5.7-9.8) for Hispanics. Hispanic and black neonates were more likely to be seen in safety-net hospitals (75.8%-78.2%) than white (57.1%) patients (P = 0.004). CONCLUSIONS: In this first nationally representative study of neonatal visits to the ED, visits were common, with the highest rates in non-Hispanic blacks. Hispanic and black neonates were more commonly seen in safety-net hospitals. Reasons for high visit rates deserve further study to determine whether hospital discharge practices and/or access to primary care are contributing factors.

Engaging GME Learners in Health System-Aligned Improvement Work in the Clinical Learning Environment.

Alignment between graduate medical education (GME) and health system priorities is foundational to meaningful engagement of residents and fellows in systems improvement work within the clinical learning environment. The Residents and Fellows Leading Interprofessional Continuous Improvement Teams program at the University of California San Francisco was designed over a decade ago to address barriers to trainee participation in health system-based improvement work. The program provides structure and support for health system-aligned trainee-led improvement projects in the clinic learning environment. Project champions (residents/fellows) from GME programs attend workshops where they learn improvement methodologies and develop proposals for health system-based improvement projects for their training programs. Proposals are supported by local faculty mentors and are reviewed and approved by GME and health systems' leaders. During the academic year, teams share their progress using visual management boards and interactive leader rounds. The health system provides a modest financial incentive for successful projects. Since the program's inception, thousands of trainees from 58 residency and fellowship programs have participated either as champions or participants in the program at least once, and in total over 300 projects have been implemented. Approximately three-quarters of the specific improvement goals were met, all projects meaningfully engaged residents and fellows, and many projects continued after the learners graduated. This active partnership between GME and a health system created a symbiotic relationship; trainees received education and support to complete improvement projects, while the health system reaped additional benefits from the alignment and impact of the projects. This partnership continues to grow with steady increases in participating programs, spread to partner health systems, and scholarship for trainees and faculty.

Simultaneously implementing pathways for improving asthma, pneumonia, and bronchiolitis care for hospitalized children: Protocol for a hybrid effectiveness-implementation, cluster-randomized trial.

BACKGROUND: Asthma, pneumonia, and bronchiolitis are the top causes of childhood hospitalization in the United States, leading to over 350,000 hospitalizations and ≈$2 billion in costs annually. The majority of these hospitalizations occur in general/community hospitals. Poor guideline adoption by clinicians contributes to poor health outcomes for children hospitalized with these illnesses, including longer recovery time/hospital stay, higher rates of intensive care unit transfer, and increased risk of hospital readmission. A prior single-center study at a children's hospital tested a multicondition clinical pathway intervention (simultaneous implementation of multiple pathways for multiple pediatric conditions) and demonstrated improved clinician guideline adherence and patient health outcomes. This intervention has not yet been studied in community hospitals, which face unique implementation barriers. OBJECTIVE: To study the implementation and effectiveness of a multicondition pathway intervention for children hospitalized with asthma, pneumonia, or bronchiolitis in community hospitals. METHODS: We will conduct a pragmatic, hybrid effectiveness-implementation, cluster-randomized trial in community hospitals around the United States (1:1 randomization to intervention vs. wait-list control). Our primary outcome will be the adoption of 2-3 evidence-based practices for each condition over a sustained period of 2 years. Secondary outcomes include hospital length of stay, ICU transfer, and readmission. DISCUSSION: This hybrid trial will lead to a comprehensive understanding of how to pragmatically and sustainably implement a multicondition pathway intervention in community hospitals and an assessment of its effects. Enrollment began in July 2022 and is projected to be completed in September 2024. Primary analysis completion is anticipated in March 2025, with reporting of results following.

Establishment of an artificial urine model in vitro and rat or pig model in vivo to evaluate urinary crystal adherence.

The current study aimed to establish an experimental model in vitro and in vivo of urinary crystal deposition on the surface of ureteral stents, to evaluate the ability to prevent crystal adhesion. Non-treated ureteral stents were placed in artificial urine under various conditions in vitro. In vivo, ethylene glycol and hydroxyproline were administered orally to rats and pigs, and urinary crystals and urinary Ca were investigated by Inductively Coupled Plasma-Optical Emission Spectrometer. in vitro, during the 3- and 4-week immersion periods, more crystals adhered to the ureteral stent in artificial urine model 1 than the other artificial urine models (p < 0.01). Comparing the presence or absence of urea in the composition of the artificial urine, the artificial urine without urea showed less variability in pH change and more crystal adhesion (p < 0.05). Starting the experiment at pH 6.3 resulted in the highest amount of crystal adhesion to the ureteral stent (p < 0.05). In vivo, urinary crystals and urinary Ca increased in rat and pig experimental models. This experimental model in vitro and in vivo can be used to evaluate the ability to prevent crystal adhesion and deposition in the development of new ureteral stents to reduce ureteral stent-related side effects in patients.

Fabrication of polydopamine/rGO Membranes for Effective Radionuclide Removal.

In this work, a novel polydopamine/reduced graphene oxide (PDA/rGO) nanofiltration membrane was prepared to efficiently and stably remove radioactive strontium ions under an alkaline environment. Through the incorporation of PDA and thermal reduction treatment, not only has the interlayer spacing of graphene oxide (GO) nanosheets been appropriately regulated but also an improved antiswelling property has been achieved. The dosage of GO, reaction time with PDA, mass ratio of PDA to GO, and thermal treatment temperature have been optimized to achieve a high-performance PDA/rGO membrane. The resultant PDA/rGO composite membrane has exhibited excellent long-term stability at pH 11 and maintains a steady strontium rejection of over 90%. Moreover, the separation mechanism of the PDA/rGO membrane has been systematically investigated and determined to be a synergistic effect of charge repulsion and size exclusion. Results have indicated that PDA/rGO could be considered as a promising candidate for the separation of Sr2+ ions from nuclear industry wastewater.