Impact of Extending Eligibility for Reinstatement of Waiting Time After Early Allograft Failure: A Decision Analysis.

RATIONALE & OBJECTIVE: The shortage of deceased donor kidneys identified for potential transplantation in the United States is exacerbated by a high proportion of deceased donor kidneys being discarded after procurement. We estimated the impact of a policy proposal aiming to increase organ utilization by extending eligibility for waiting time reinstatement for recipients experiencing early allograft failure after transplantation. STUDY DESIGN: Decision analysis informed by clinical registry data. SETTING & POPULATION: We used Organ Procurement and Transplantation Network data to identify 76,044 deceased-donor kidneys procured in the United States from 2013 to 2017, 80% of which were transplanted and 20% discarded. INTERVENTION: Extend waiting time reinstatement for recipients experiencing allograft failure from the current 90 days to 1 year after transplantation. OUTCOME: Net impact to the waitlist, defined as the estimated number of additional transplants minus estimated increase in waiting list reinstatements. MODEL, PERSPECTIVE, & TIMEFRAME: We estimated (1) the number of additional deceased donor kidneys that would be transplanted if there was a 5%-25% relative reduction in discards, and (2) the number of recipients who would regain waiting time under a 6-, 12-, 18-, and 24-month reinstatement policy. RESULTS: Reinstating a waiting time for recipients experiencing allograft failure up to 1 year after transplantation yielded more additional transplants than growth in additions to the waiting list for all model assumptions except the combination of a very low relative reduction in discards (5%) and a very high failure rate of transplanted kidneys that would previously have been discarded (≥5 times the rate of currently transplanted kidneys). LIMITATIONS: Lack of empirical evidence supporting the proposed impact of such a policy change. CONCLUSIONS: A policy change reinstating waiting time for deceased donor kidneys recipients with allograft failure up to 1 year after transplantation should explored as a decision science-based intervention to improve organ utilization.

Characterizing COVID-19: A chief complaint based approach.

BACKGROUND: The COVID-19 pandemic has inundated emergency departments with patients exhibiting a wide array of symptomatology and clinical manifestations. We aim to evaluate the chief complaints of patients presenting to our ED with either suspected or confirmed COVID-19 to better understand the clinical presentation of this pandemic. METHODS: This study was a retrospective computational analysis that investigated the chief complaints of all confirmed and suspected COVID-19 cases presenting to our adult ED (patients aged 22 and older) using a variety of data mining methods. Our study employed descriptive statistics to analyze the set of complaints that are most common, hierarchical clustering analysis to provide a nuanced way of identifying complaints that co-occur, and hypothesis testing identify complaint differences among age differences. RESULTS: A quantitative analysis of 5015 ED visits of COVID-suspected patients (1483 confirmed COVID-positive patients) identified 209 unique chief complaints. Of the 209 chief complaints, fever and shortness of breath were the most prevalent initial presenting symptoms. In the subset of COVID-19 confirmed positive cases, we discovered seven distinct clusters of presenting complaints. Patients over 65 years of age were more likely to present with weakness and altered mental status. CONCLUSIONS: Our research highlights an important aspect of the evaluation and management of COVID-19 patients in the emergency department. Our study identified most common chief complaints, chief complaints differences across age groups, and 7 distinct groups of COVID-19 symptoms. This large-scale effort to classify the most commonly reported symptoms in ED patients provides public health officials and providers with data for identifying COVID-19 cases.

Creation of an Automated and Comprehensive Resident Progress System for Residents and to Save Hours of Faculty Time: Mixed Methods Study.

BACKGROUND: It is vital for residents to have a longitudinal view of their educational progression, and it is crucial for the medical education team to have a clear way to track resident progress over time. Current tools for aggregating resident data are difficult to use and do not provide a comprehensive way to evaluate and display resident educational advancement. OBJECTIVE: This study aims to describe the creation and assessment of a system designed to improve the longitudinal presentation, quality, and synthesis of educational progress for trainees. We created a new system for residency progress management with 3 goals in mind, that are (1) a long-term and centralized location for residency education data, (2) a clear and intuitive interface that is easy to access for both the residents and faculty involved in medical education, and (3) automated data input, transformation, and analysis. We present evaluations regarding whether residents find the system useful, and whether faculty like the system and perceive that it helps them save time with administrative duties. METHODS: The system was created using a suite of Google Workspace tools including Forms, Sheets, Gmail, and a collection of Apps Scripts triggered at various times and events. To assess whether the system had an effect on the residents, we surveyed and asked them to self-report on how often they accessed the system and interviewed them as to whether they found it useful. To understand what the faculty thought of the system, we conducted a 14-person focus group and asked the faculty to self-report their time spent preparing for residency progress meetings before and after the system debut. RESULTS: The system went live in February 2022 as a quality improvement project, evolving through multiple iterations of feedback. The authors found that the system was accessed differently by different postgraduate years (PGY), with the most usage reported in the PGY1 class (weekly), and the least amount of usage in the PGY3 class (once or twice). However, all of the residents reported finding the system useful, specifically for aggregating all of their evaluations in the same place. Faculty members felt that the system enabled a more high-quality biannual clinical competency committee meeting and they reported a combined time savings of 8 hours in preparation for each clinical competency committee as a result of reviewing resident data through the system. CONCLUSIONS: Our study reports on the creation of an automated, instantaneous, and comprehensive resident progress management system. The system has been shown to be well-liked by both residents and faculty. Younger PGY classes reported more frequent system usage than older PGY classes. Faculty reported that it helped facilitate more meaningful discussion of training progression and reduced the administrative burden by 8 hours per biannual session.

Trends in cannabis use in New Jersey: Effects of COVID-19 and cannabis legalization.

Objectives: With the legalization of cannabis in New Jersey on April 21, 2022, including the licensing of cannabis dispensaries, concerns have arisen about potential adverse events related to cannabis use. Here, we explore temporal trends and risk factors for cannabis-related harm in both adult and pediatric cannabis-related visits at a tertiary care academic institution. Methods: We performed a retrospective chart review and temporal trend analysis via the electronic health record from May 1, 2019 to October 31, 2022, covering 2 years before, and 6 months after, cannabis legalization in New Jersey. The pediatric charts identified were analyzed for root causes of adverse events, and changes in the frequency of specific unsafe practices since cannabis legalization were tracked. Results: We found that adult cannabis ED-related visits significantly increased during the COVID-19 pandemic and remained higher than pre-pandemic levels for the remainder of the study periods, without a significant change upon legalization. Pediatric rates of cannabis-related ED visits did not vary significantly during the study period. The vast majority of visits for children aged 0-12 years were related to accidental cannabis exposures-often a household member's edibles-whereas most visits for older children stemmed from intentional cannabis use. Conclusion: This project highlights the unintended consequences of wider cannabis access in New Jersey. Notably, cannabis use increased even before its legalization, presumably in response to the COVID-19 pandemic and its attendant mental health effects. Rates of cannabis use disorder and its highlight of other concurrent psychiatric disorders are important topics for both clinicians and lawmakers to consider.

Characterization of Electronic Health Record Documentation Shortcuts: Does the use of dotphrases increase efficiency in the Emergency Department?

The problem of clinical documentation burden is ever-growing. Electronic documentation tools such as "dotphrases" were invented to help with the documentation burden. Despite the ubiquity of these tools, they are understudied. We present work on the usage of dotphrases within the emergency department. We find that dotphrases are most often used by medical scribes, they significantly increase note length, and are completely unstandardized as to their naming conventions, content, and usage. We find that there is inconsistent usage across and within providers and that there is much duplication in the dotphrase content. We also show that dotphrases have no effect on the time to complete and cosign a note. Finally, we demonstrate that even when accounting for patient complexity upon presentation, note authorship, and note length - notes with higher dotphrase usage are billed at higher billing levels.

Identifying the risk factors for catheter-associated urinary tract infections: a large cross-sectional study of six hospitals.

MOTIVATION: Catheter-associated urinary tract infections (CAUTI) are a common and serious healthcare-associated infection. Despite many efforts to reduce the occurrence of CAUTI, there remains a gap in the literature about CAUTI risk factors, especially pertaining to the effect of catheter dwell-time on CAUTI development and patient comorbidities. OBJECTIVE: To examine how the risk for CAUTI changes over time. Additionally, to assess whether time from catheter insertion to CAUTI event varied according to risk factors such as age, sex, patient type (surgical vs medical) and comorbidities. DESIGN: Retrospective cohort study of all patients who were catheterised from 2012 to 2016, including those who did and did not develop CAUTIs. Both paediatric and adult patients were included. Indwelling urinary catheterisation is the exposure variable. The variable is interval, as all participants were exposed but for different lengths of time. SETTING: Urban academic health system of over 2500 beds. The system encompasses two large academic medical centres, two community hospitals and a paediatric hospital. RESULTS: The study population was 47 926 patients who had 61 047 catheterisations, of which 861 (1.41%) resulted in a CAUTI. CAUTI rates were found to increase non-linearly for each additional day of catheterisation; CAUTI-free survival was 97.3% (CI: 97.1 to 97.6) at 10 days, 88.2% (CI: 86.9 to 89.5) at 30 days and 71.8% (CI: 66.3 to 77.8) at 60 days. This translated to an instantaneous HR of. 49%-1.65% in the 10-60 day time range. Paraplegia, cerebrovascular disease and female sex were found to statistically increase the chances of a CAUTI. CONCLUSIONS: Using a very large data set, we demonstrated the incremental risk of CAUTI associated with each additional day of catheterisation, as well as the risk factors that increase the hazard for CAUTI. Special attention should be given to patients carrying these risk factors, for example, females or those with mobility issues.

A principled framework for phenotyping postpartum hemorrhage across multiple levels of severity.

Maternal morbidity and mortality have gained major attention recently, spurred on by rising domestic rates even as maternal mortality decreases in Europe. A major driver of morbidity and mortality among delivering women is postpartum hemorrhage (PPH). PPH is currently phenotyped using the subjective measure of 'Estimated blood loss' (EBL), which has been shown to be unreliable for tracking quality. Here we present a framework for phenotyping PPH into multiple severity levels, using a combination of data-driven techniques and expert-derived clinical indicators. We validate the framework by predicting large drops in hematocrit and quantitative blood loss, finding that the framework performs better in predicting coded PPH than a hematocrit-based predictor or predictors based on other metrics such as blood transfusions, and does better in predicting quantitative blood loss, a gold standard metric for blood loss that we have for a subset of patients, than any predictor we could build using hematocrit drops alone. In all, we present a principled framework that can be used to phenotype PPH in hospitals using readily available EHR data, and that will perform with more granularity and accuracy than existing methods.

Improving Emergency Department Flow: Reducing Turnaround Time for Emergent CT Scans.

Emergency departments across the U.S. are more congested than ever, and there is a pressing need to create capacity by improving patient flow. The long turnaround time of imaging tests, such as computed tomography (CT) scans, are a major reason for delays in treatment and disposition. Over an eight-month pre-intervention period during which 10,063 CT scans were ordered in our emergency department, the average time from a CT order to the availability of the radiologist's final report was 5.9 hours (median=4.2 hours). We created a multi-disciplinary team of physicians, nurses, technicians, transporters, informaticians, and engineers to identify barriers and implement technical as well as human-factors solutions. In the corresponding eight-month period after the implementation of the intervention bundle, there was a 1.2 hour reduction in CT turnaround time, despite a 13.8% increase in the number of CT scans ordered (p<0.0001).

Reducing indwelling urinary catheter use through staged introduction of electronic clinical decision support in a multicenter hospital system.

OBJECTIVE: To integrate electronic clinical decision support tools into clinical practice and to evaluate the impact on indwelling urinary catheter (IUC) use and catheter-associated urinary tract infections (CAUTIs).Design, Setting, and ParticipantsThis 4-phase observational study included all inpatients at a multicampus, academic medical center between 2011 and 2015.InterventionsPhase 1 comprised best practices training and standardization of electronic documentation. Phase 2 comprised real-time electronic tracking of IUC duration. In phase 3, a triggered alert reminded clinicians of IUC duration. In phase 4, a new IUC order (1) introduced automated order expiration and (2) required consideration of alternatives and selection of an appropriate indication. RESULTS: Overall, 2,121 CAUTIs, 179,070 new catheters, 643,055 catheter days, and 2,186 reinsertions occurred in 3·85 million hospitalized patient days during the study period. The CAUTI rate per 10,000 patient days decreased incrementally in each phase from 9·06 in phase 1 to 1·65 in phase 4 (relative risk [RR], 0·182; 95% confidence interval [CI], 0·153-0·216; P<·001). New catheters per 1,000 patient days declined from 53·4 in phase 1 to 39·5 in phase 4 (RR, 0·740; 95% CI, 0·730; P<·001), and catheter days per 1,000 patient days decreased from 194·5 in phase 1 to 140·7 in phase 4 (RR, 0·723; 95% CI, 0·719-0·728; P<·001). The reinsertion rate declined from 3·66% in phase 1 to 3·25% in phase 4 (RR, 0·894; 95% CI, 0·834-0·959; P=·0017). CONCLUSIONS: The phased introduction of decision support tools was associated with progressive declines in new catheters, total catheter days, and CAUTIs. Clinical decision support tools offer a viable and scalable intervention to target hospital-wide IUC use and hold promise for other quality improvement initiatives.

Engaging hospital patients in the medication reconciliation process using tablet computers.

Objective: Unintentional medication discrepancies contribute to preventable adverse drug events in patients. Patient engagement in medication safety beyond verbal participation in medication reconciliation is limited. We conducted a pilot study to determine whether patients' use of an electronic home medication review tool could improve medication safety during hospitalization. Materials and Methods: Patients were randomized to use a tool before or after hospital admission medication reconciliation to review and modify their home medication list. We assessed the quantity, potential severity, and potential harm of patients' and clinicians' medication changes. We also surveyed clinicians to assess the tool's usefulness. Results: Of 76 patients approached, 65 (86%) participated. Forty-eight (74%) made changes to their home medication list [before: 29 (81%), after: 19 (66%), p = .170]. Before group participants identified 57 changes that clinicians subsequently missed on admission medication reconciliation. Thirty-nine (74%) had a significant or greater potential severity, and 19 (36%) had a greater than 50-50 chance of harm. After group patients identified 68 additional changes to their reconciled medication lists. Fifty-one (75%) had a significant or greater potential severity, and 33 (49%) had a greater than 50-50 chance of harm. Clinicians reported believing that the tool would save time, and patients would supply useful information. Discussion: The results demonstrate a high willingness of patients to engage in medication reconciliation, and show that patients were able to identify important medication discrepancies and often changes that clinicians missed. Conclusion: Engaging patients in admission medication reconciliation using an electronic home medication review tool may improve medication safety during hospitalization.