C. Jessica Dine

Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing

Objective:Delivery of high-quality cardiopulmonary resuscitation increases survival from cardiac arrest, yet studies have shown that cardiopulmonary resuscitation quality is often poor during actual in-hospital resuscitation. Furthermore, recent work has shown that audiovisual feedback alone during cardiopulmonary resuscitation modestly improves performance. We hypothesized that a multimodal training method comprising audiovisual feedback and immediate debriefing would improve cardiopulmonary resuscitation performance among care providers. Design:Prospective randomized interventional study. Setting:Simulated cardiac arrests at an academic medical center. Subjects:A total of 80 nurses were randomized to two groups. Intervention:Each group underwent three trials of simulated cardiac arrest. The “feedback” group received real-time audiovisual feedback during the second and third trials, whereas the “debriefing-only” group performed cardiopulmonary resuscitation without feedback. Both groups received short individual debriefing after the second trial. Measurements:Cardiopulmonary resuscitation quality was recorded using a cardiopulmonary resuscitation-sensing defibrillator that measures chest compression rate/depth and can deliver audiovisual feedback messages from both groups during the three trials. An adequate compression rate was defined as 90–110 compressions/min and an adequate depth as 38–51 mm. Main Results:In the debriefing-only group, the percentage of participants providing compressions of adequate depth increased after debriefing, from 38% to 68% (p = 0.015). In the feedback group, depth compliance improved from 19% to 58% (p = 0.002). Compression rate did not improve significantly with either intervention alone. The combination of feedback and debriefing improved compression rate compliance from 45% to 84% (p = 0.001) and resulted in a doubling of participants providing compressions of both adequate rate and depth, 29% vs. 64% (p = 0.005). Conclusions:Significant cardiopulmonary resuscitation quality deficits exist among healthcare providers. Debriefing or feedback alone improved cardiopulmonary resuscitation quality, but the combination led to marked performance improvements. Cardiopulmonary resuscitation feedback and debriefing may serve as a powerful tool to improve rescuer training and care for cardiac arrest patients.

Effect of a Protected Sleep Period on Hours Slept During Extended Overnight In-hospital Duty Hours Among Medical Interns: A Randomized Trial

CONTEXT A 2009 Institute of Medicine report recommended protected sleep periods for medicine trainees on extended overnight shifts, a position reinforced by new Accreditation Council for Graduate Medical Education requirements. OBJECTIVE To evaluate the feasibility and consequences of protected sleep periods during extended duty. DESIGN, SETTING, AND PARTICIPANTS Randomized controlled trial conducted at the Philadelphia VA Medical Center medical service and Oncology Unit of the Hospital of the University of Pennsylvania (2009-2010). Of the 106 interns and senior medical students who consented, 3 were not scheduled on any study rotations. Among the others, 44 worked at the VA center, 16 at the university hospital, and 43 at both. INTERVENTION Twelve 4-week blocks were randomly assigned to either a standard intern schedule (extended duty overnight shifts of up to 30 hours; equivalent to 1200 overnight intern shifts at each site), or a protected sleep period (protected time from 12:30 AM to 5:30 AM with handover of work cell phone; equivalent to 1200 overnight intern shifts at each site). Participants were asked to wear wrist actigraphs and complete sleep diaries. MAIN OUTCOME MEASURES Primary outcome was hours slept during the protected period on extended duty overnight shifts. Secondary outcome measures included hours slept during a 24-hour period (noon to noon) by day of call cycle and Karolinska sleepiness scale. RESULTS For 98.3% of on-call nights, cell phones were signed out as designed. At the VA center, participants with protected sleep had a mean 2.86 hours (95% CI, 2.57-3.10 hours) of sleep vs 1.98 hours (95% CI, 1.68-2.28 hours) among those who did not have protected hours of sleep (P < .001). At the university hospital, participants with protected sleep had a mean 3.04 hours (95% CI, 2.77-3.45 hours) of sleep vs 2.04 hours (95% CI, 1.79-2.24) among those who did not have protected sleep (P < .001). Participants with protected sleep were significantly less likely to have call nights with no sleep: 5.8% (95% CI, 3.0%-8.5%) vs 18.6% (95% CI, 13.9%-23.2%) at the VA center (P < .001) and 5.9% (95% CI, 3.1%-8.7%) vs 14.2% (95% CI, 9.9%-18.4%) at the university hospital (P = .001). Participants felt less sleepy after on-call nights in the intervention group, with Karolinska sleepiness scale scores of 6.65 (95% CI, 6.35-6.97) vs 7.10 (95% CI, 6.85-7.33; P = .01) at the VA center and 5.91 (95% CI, 5.64-6.16) vs 6.79 (95% CI, 6.57-7.04; P < .001) at the university hospital. CONCLUSIONS For internal medicine services at 2 hospitals, implementation of a protected sleep period while on call resulted in an increase in overnight sleep duration and improved alertness the next morning. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00874510.

Lung Volumes: Measurement, Clinical Use, and Coding

Measurement of lung volumes is an integral part of complete pulmonary function testing. Some lung volumes can be measured during spirometry; however, measurement of the residual volume (RV), functional residual capacity (FRC), and total lung capacity (TLC) requires special techniques. FRC is typically measured by one of three methods. Body plethysmography uses Boyles Law to determine lung volumes, whereas inert gas dilution and nitrogen washout use dilution properties of gases. After determination of FRC, expiratory reserve volume and inspiratory vital capacity are measured, which allows the calculation of the RV and TLC. Lung volumes are commonly used for the diagnosis of restriction. In obstructive lung disease, they are used to assess for hyperinflation. Changes in lung volumes can also be seen in a number of other clinical conditions. Reimbursement for measurement of lung volumes requires knowledge of current procedural terminology (CPT) codes, relevant indications, and an appropriate level of physician supervision. Because of recent efforts to eliminate payment inefficiencies, the 10 previous CPT codes for lung volumes, airway resistance, and diffusing capacity have been bundled into four new CPT codes.

Effect of Attending Practice Style on Generic Medication Prescribing by Residents in the Clinic Setting: An Observational Study.

BackgroundDespite increased emphasis on cost-consciousness in graduate medical training, there is little empirical evidence of the role of attending physician supervision on resident practice in this area.ObjectiveTo study whether the prescribing practices of attendings influence residents’ prescribing of brand-name statin medications in the ambulatory clinic setting.Design and ParticipantsA retrospective study of statin prescriptions by residents at two internal medicine residency programs, using electronic medical record data from July 2007 through November 2011.Main MeasuresWe estimated multivariable hierarchical logistic regression models to assess the independent effect of the supervising attending’s rate of brand-name prescribing in the preceding quarter on the likelihood of a resident prescribing a brand-name statin.Key ResultsThe sample included 342 residents and 58 attendings, accounting for 10,151 initial statin prescriptions, including 3,942 by residents. Brand-name statins were prescribed in about one-fourth of encounters. After adjusting for patient-, physician-, and practice-level factors, the supervising attendings’ brand-name prescribing rate in the quarter preceding the encounter was positively associated with a postgraduate year (PGY)-1 resident’s prescribing a brand-name statin, but not for PGY-2 or PGY-3 residents. For PGY-1 residents, the adjusted probability of a resident prescribing a brand-name statin ranged from 22.6 % (95 % CI 17.3–28.0 %, p < 0.001) for residents supervised by an attending who prescribed < 20 % brand-name statins in the previous quarter to 41.6 % (95 % CI 24.6–58.5 %, p < 0.001) for residents supervised by an attending who prescribed at least 80 % brand-name statins in the previous quarter. A higher PGY level was associated with brand-name prescribing (aOR 2.07, 95 % CI 1.28–3.35, p = 0.003 for PGY-2; aOR 2.15, 95 % CI 1.31–3.55, p = 0.003 for PGY-3, vs. PGY-1).ConclusionsSupervising attendings’ prescribing of brand-name medications may have a significant influence on PGY-1 residents’ prescribing of brand-name medications, but not on prescribing by more senior residents.

Therapeutic Hypothermia for Neuroprotection

This review briefly discusses induced therapeutic hypothermia (TH), which represents the intentional induction of a lowered core body temperature of 35 degrees C or less. The focus is on resuscitative or postarrest hypothermia, the data that support it, and the practical issues pertaining to TH implementation.

Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests: The PRICE Randomized Clinical Trial

Importance Many health systems are considering increasing price transparency at the time of order entry. However, evidence of its impact on clinician ordering behavior is inconsistent and limited to single-site evaluations of shorter duration. Objective To test the effect of displaying Medicare allowable fees for inpatient laboratory tests on clinician ordering behavior over 1 year. Design, Setting, and Participants The Pragmatic Randomized Introduction of Cost data through the electronic health record (PRICE) trial was a randomized clinical trial comparing a 1-year intervention to a 1-year preintervention period, and adjusting for time trends and patient characteristics. The trial took place at 3 hospitals in Philadelphia between April 2014 and April 2016 and included 98 529 patients comprising 142 921 hospital admissions. Interventions Inpatient laboratory test groups were randomly assigned to display Medicare allowable fees (30 in intervention) or not (30 in control) in the electronic health record. Main Outcomes and Measures Primary outcome was the number of tests ordered per patient-day. Secondary outcomes were tests performed per patient-day and Medicare associated fees. Results The sample included 142 921 hospital admissions representing patients who were 51.9% white (74 165), 38.9% black (55 526), and 56.9% female (81 291) with a mean (SD) age of 54.7 (19.0) years. Preintervention trends of order rates among the intervention and control groups were similar. In adjusted analyses of the intervention group compared with the control group over time, there were no significant changes in overall test ordering behavior (0.05 tests ordered per patient-day; 95% CI, −0.002 to 0.09; P = .06) or associated fees (

U.S. Internal Medicine Residents' Knowledge and Practice of High-Value Care: A National Survey.

0.24 per patient-day; 95% CI, −

A randomized trial of a three-hour protected nap period in a medicine training program: sleep, alertness, and patient outcomes.

0.42 to

Team Effect on Variation in Laboratory Utilization on Subspecialty Services

0.91; P = .47). Exploratory subset analyses found small but significant differences in tests ordered per patient-day based on patient intensive care unit (ICU) stay (patients with ICU stay: −0.16; 95% CI, −0.31 to −0.01; P = .04; patients without ICU stay: 0.13; 95% CI, 0.08-0.17; P < .001) and the magnitude of associated fees (top quartile of tests based on fee value: −0.01; 95% CI, −0.02 to −0.01; P = .04; bottom quartile: 0.03; 95% CI, 0.002-0.06; P = .04). Adjusted analyses of tests that were performed found a small but significant overall increase in the intervention group relative to the control group over time (0.08 tests performed per patient day, 95% CI, 0.03-0.12; P < .001). Conclusions and Relevance Displaying Medicare allowable fees for inpatient laboratory tests did not lead to a significant change in overall clinician ordering behavior or associated fees. Trial Registration clinicaltrials.gov Identifier: NCT02355496

Impact of Protected Sleep Period for Internal Medicine Interns on Overnight Call on Depression, Burnout, and Empathy

Purpose To determine U.S. internal medicine (IM) residents’ knowledge of, attitudes toward, and self-reported practice of high-value care (HVC), or care that balances the benefits, harms, and costs of tests and treatments. Method The authors conducted a cross-sectional survey of U.S. IM residents who took the Internal Medicine In-Training Examination in October 2012. They used multivariable mixed-effects models to examine the relationships between self-reported knowledge and practice of HVC and both exposure to HVC teaching and the care intensity of the training hospital (based on a composite age–sex–race–illness standardized measure of hospital days and inpatient physician visits by Medicare recipients). Results Of 21,617 residents who received the survey, 18,102 (83.7%) completed it. Self-reported HVC practices varied: 4,187 of 17,633 respondents (23.7%) agreed that they “share estimated costs of tests and treatments with patients”; 15,549 of 17,626 (88.2%) agreed that they “incorporate patients’ values and concerns into clinical decisions.” Discussions about balancing the benefits, harms, and costs of treatments with faculty during patient care at least a few times a week were reported by 7,103 of 17,704 respondents (40.1%) and were associated with all self-reported HVC practices. The training hospital’s care intensity was inversely associated with self-reported incorporation of costs and patient values into clinical decisions but not with other self-reported behaviors. Conclusions U.S. IM residents reported varying HVC knowledge and practice. Faculty discussions of HVC during patient care correlated with such knowledge and practice and may represent an opportunity to improve residents’ competency in providing value-based care.