Stephanie Taylor

We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication

Background Increasing attention is being given to the importance of communication in the delivery of high-quality healthcare. We sought to determine whether communication improved in a hospital setting following the introduction of an electronic medical record (EMR). Methods This pre-post cohort design enrolled 75 patient-nurse-physician triads prior to the introduction of EMR, and 123 triads after the introduction of EMR. Nurses and patients reported whether they communicated with the physician that day. Patients, nurses and physicians answered several questions about the plan of care for the day. Responses were scored for degree of agreement and compared between pre-EMR and post-EMR cohorts. The primary outcome was Total Agreement Score, calculated as the sum of the agreement responses. Chart review was performed to determine patients’ actual length of stay. Results Although there was no difference between the frequency of nurses reporting communication with physicians before and after EMR, face-to-face communication was significantly reduced (67% vs 51%, p=0.03). Total Agreement Score was significantly lower after the implementation of EMR (p=0.03). Additionally, fewer patients accurately predicted their expected length of stay after EMR (34% vs 26%, p=0.001). Conclusions The implementation of EMR was associated with a decrease in face-to-face communication between physicians and nurses, and worsened overall agreement about the plan of care.

How do physicians decide to treat: an empirical evaluation of the threshold model

BackgroundAccording to the threshold model, when faced with a decision under diagnostic uncertainty, physicians should administer treatment if the probability of disease is above a specified threshold and withhold treatment otherwise. The objectives of the present study are to a) evaluate if physicians act according to a threshold model, b) examine which of the existing threshold models [expected utility theory model (EUT), regret-based threshold model, or dual-processing theory] explains the physicians’ decision-making best.MethodsA survey employing realistic clinical treatment vignettes for patients with pulmonary embolism and acute myeloid leukemia was administered to forty-one practicing physicians across different medical specialties. Participants were randomly assigned to the order of presentation of the case vignettes and re-randomized to the order of “high” versus “low” threshold case. The main outcome measure was the proportion of physicians who would or would not prescribe treatment in relation to perceived changes in threshold probability.ResultsFewer physicians choose to treat as the benefit/harms ratio decreased (i.e. the threshold increased) and more physicians administered treatment as the benefit/harms ratio increased (and the threshold decreased). When compared to the actual treatment recommendations, we found that the regret model was marginally superior to the EUT model [Odds ratio (OR) = 1.49; 95% confidence interval (CI) 1.00 to 2.23; p = 0.056]. The dual-processing model was statistically significantly superior to both EUT model [OR = 1.75, 95% CI 1.67 to 4.08; p < 0.001] and regret model [OR = 2.61, 95% CI 1.11 to 2.77; p = 0.018].ConclusionsWe provide the first empirical evidence that physicians’ decision-making can be explained by the threshold model. Of the threshold models tested, the dual-processing theory of decision-making provides the best explanation for the observed empirical results.

Evaluation of Physicians' Cognitive Styles.

Background. Patient outcomes critically depend on accuracy of physicians’ judgment, yet little is known about individual differences in cognitive styles that underlie physicians’ judgments. The objective of this study was to assess physicians’ individual differences in cognitive styles relative to age, experience, and degree and type of training. Methods. Physicians at different levels of training and career completed a web-based survey of 6 scales measuring individual differences in cognitive styles (maximizing v. satisficing, analytical v. intuitive reasoning, need for cognition, intolerance toward ambiguity, objectivism, and cognitive reflection). We measured psychometric properties (Cronbach’s α) of scales; relationship of age, experience, degree, and type of training; responses to scales; and accuracy on conditional inference task. Results. The study included 165 trainees and 56 attending physicians (median age 31 years; range 25–69 years). All 6 constructs showed acceptable psychometric properties. Surprisingly, we found significant negative correlation between age and satisficing (r = −0.239; P = 0.017). Maximizing (willingness to engage in alternative search strategy) also decreased with age (r = −0.220; P = 0.047). Number of incorrect inferences negatively correlated with satisficing (r = −0.246; P = 0.014). Disposition to suppress intuitive responses was associated with correct responses on 3 of 4 inferential tasks. Trainees showed a tendency to engage in analytical thinking (r = 0.265; P = 0.025), while attendings displayed inclination toward intuitive-experiential thinking (r = 0.427; P = 0.046). However, trainees performed worse on conditional inference task. Conclusion. Physicians capable of suppressing an immediate intuitive response to questions and those scoring higher on rational thinking made fewer inferential mistakes. We found a negative correlation between age and maximizing: Physicians who were more advanced in their careers were less willing to spend time and effort in an exhaustive search for solutions. However, they appeared to have maintained their “mindware” for effective problem solving.

Rapid diagnosis of Mycobacterium abscessus endophthalmitis.

Nontuberculous mycobacteria are widely distributed in the environment and have the potential to cause a wide spectrum of infections including pulmonary, bone, soft tissue or ocular infections. They are a rare cause of endophthalmitis, a potentially devastating condition, which may be acquired through contamination of water or antiseptic solutions. Diagnosis is often delayed due to low clinical suspicion, resulting in poor clinical outcomes. Newer laboratory techniques such as real-time PCR can be used for rapid detection, identification and speciation of mycobacteria and allow for initiation of focused antibiotic therapy. We describe a case of Mycobacterium abscessus endophthalmitis that developed 30 years after traumatic loss of cornea in a patient with diabetes mellitus.

A Case of Chyloperitoneum Secondary to Follicular Lymphoma and a Review of Prognostic Implications

Chyloperitoneum, or chylous ascites, is a rare condition characterized by milky-appearing fluid with elevated triglyceride content and the presence of chylomicrons. Malignancy, specifically lymphoma, is reported to be the predominant cause in Western countries. Previously, the prognosis for patients with chyloperitoneum due to lymphoma has been reported as poor. We present a case of chyloperitoneum and chylothorax due to follicular lymphoma with excellent response to bendamustine and Rituxan. A review of the literature indicates that patients with chyloperitoneum associated with lymphoma generally have a favorable response to contemporary treatment regimens.

Early versus delayed right heart catheterization in evaluation of pulmonary arterial hypertension

When pulmonary arterial hypertension (PAH) is suspected by clinical signs and symptoms, screening echocardiography is recommended for initial evaluation of the disease. Because of the inherent inaccuracy of echocardiographic estimates of pulmonary pressures, right heart catheterization (RHC) is the standard of care for assessing pulmonary vascular hemodynamics and confirming PAH. However, current diagnostic algorithms for PAH do not stress the importance of confirmation of PAH with RHC. Guidelines recommend that a work-up for underlying causes be performed prior to confirmation of PAH by RHC. We conducted a retrospective review of patients referred for RHC based on echocardiographic findings to illustrate the importance of confirming PAH by RHC early in the diagnostic process. We retrospectively reviewed 190 patients with pulmonary artery systolic pressure (PaSP) 440 mm Hg on transthoracic echocardiogram who also underwent RHC at Tampa General Hospital between January 2007 and October 2009. The average mean pulmonary artery pressure (mPAP) at RHC was compared with the average PaSP by echocardiogram using Pearson’s correlation. World Health Organization (WHO) Group 1 PAH was diagnosed if mean pulmonary artery pressure (mPAP) was 425 mm Hg with a pulmonary artery wedge pressure (PaWP) of r15 mm Hg, and WHO Group 2 PAH was diagnosed if mPAP was 425 mm Hg and PaWP was 415 mm Hg. The positive predictive value of echocardiography to predict a diagnosis of PAH at RHC was calculated. Institutional review board approval (No. 108617) for this study was obtained from the University of South Florida. Table 1 shows the characteristics of the study population. There was a modest correlation between PaSP obtained by echocardiography and PaSP obtained at RHC (r 1⁄4 0.68, p o 0.001). The distribution of RHC results is shown in Fig. 1 Only 67 of 190 patients (35%) with elevated PaSP on echocardiogram met the criteria for the diagnosis of WHO Group 1 PAH. Seventy of 190 patients (37%) with elevated PaSP on echocardiogram had mPAP r25 mm Hg at RHC. Interestingly, 53 of 190 patients (28%) with elevated PASP on echocardiogram and mPAP 425 mm Hg on RHC were reclassified as WHO Group 2 PAH (pulmonary venous hypertension). In this study, only about one third of patients referred for RHC based on elevated PaSP on echocardiography actually had WHO Group 1 PAH. One third of patients were reclassified as WHO Group 2 PAH based on elevated PaWP, and one third had normal mPAP measured directly on RHC. Although there was a modest correlation between

1493: INITIAL FLUID BY ADJUSTED BODY WEIGHT LINKED TO LOWER MORTALITY IN OBESE PATIENTS WITH SEPTIC SHOCK

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Sepsis Associated Macrophage Activation Syndrome (S-MAS) occurs in children, but little is known about S-MAS in adults. We conducted a systematic review to investigate rates, mortality, pattern of organ compromise and treatment strategies for adult S-MAS. Methods: We reviewed EMBASE, Cochrane and MEDLINE 20012017, using medical subject heading terms and text words with Boolean logic. We included observational and interventional studies in adult (> 18 y) patients with sepsis/infection and MAS, or hemophagocytic lymphohystiocytosis (S-HLH). We excluded studies enrolling patients with rheumatological disorders, family history of HLH or malignancy. Results: We found 3,692 articles and excluded 3,663 for duplications, not reporting outcomes, and including patients with rheumatologic conditions, malignancies or < 18 years. We selected 29 articles, including 1,272 patients -10 case reports, 1 case series, 17 cohort studies, and 1 post-hoc analysis of a randomized trial (ph-RCT) on IL-1R antagonist (IL-1Ra) for treatment of sepsis. Only the ph-RCT reported on the rate of S-MAS (6.1%). Mortality was reported in 12 studies, ranging from 50% in case reports to 60% in the ph-RCT. Six studies reported on organ dysfunction, most often citing hepatobiliary and renal compromise. All 29 studies reported treatment. Eight studies of S-MAS reported treatment with pulse methylprednisolone+etoposide, IL-1Ra, cyclosporine, intravenous immunoglobulin (IVIG)+fresh frozen plasma, IVIG+prednisolone. A case series described 3 patients treated with IL-1Ra and IVIG +/steroids, with 50% survival. The ph-RCT reported mortality reduction from 60 to 29.7% with Anti-IL-1Ra. Nineteen studies on S-HLH reported as most common treatments steroids +/etoposide, etoposide, cyclosporine, IVIG, plasmapheresis, stem cell transplant and Alemtuzumab. Conclusions: There is very little evidence on the frequency, outcome, and potential therapeutic interventions in adult S-MAS. Although the incidence is low, mortality is very high. Treatment strategies varied, however, the best evidence suggested a promising therapeutic role for IL-1Ra.

1477: DELAYS FROM FIRST TO SECOND ANTIBIOTIC ADMINISTRATION IN EMERGENCY DEPARTMENT PATIENTS WITH SEPSIS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Robust evidence links timely administration of antibiotics to good outcomes in patients with sepsis. Current guidelines recommend an ambitious goal of antibiotic administration within 1 hour from “time zero”. Little is known about the timing of key processes from Emergency Department (ED) arrival to antibiotic administration for patients with sepsis. Methods: We studied patients presenting to the ED with sepsis (defined as suspected infection and organ dysfunction) at two hospitals with mature sepsis treatment pathways including order sets with preselected antibiotic regimens. We conceptualized the total time from ED arrival to antibiotic administration into 3 intervals. Interval 1: time from arrival to the time a physician opens the patient’s medical record (door to doctor time), Interval 2: time from chart open to entering the antibiotic order (doctor to decision time) and Interval 3: time from order entry to administration of the antibiotic (decision to drug time). We retrospectively abstracted these times from medical records. Because we were specifically interested in how antibiotic allergies might affect delays, we recorded whether patients had allergy to any of the preselected antibiotics. Results: Of 155 patients presenting to the ED with sepsis, 18.7% (28) died during hospitalization. Overall, a mean time of 119.08 minutes (SD 88.8) elapsed between ED arrival and antibiotic administration. The mean time between ED arrival and chart opening by a physician was 16.9 minutes (SD 29.8), the mean time required for physicians to enter an antibiotic order was 68.2 minutes (SD 60.5), followed by another mean time of 40.2 minutes (SD 38.2) to begin drug infusion. Patients with allergy to the preselected antibiotics experienced a longer delay from antibiotic order to administration (36.3 vs 50.1 min, p = 0.09) and longer total delay from chart open to administration (101.6 vs 125.2 min, p = 0.16), but similar time from chart open to placement of antibiotic order (65.3 vs 75.7 min, p = 0.43). Conclusions: In order to reduce ED delays in antibiotic administration for patients with sepsis, we examined the critical phases between arrival and treatment. We report average times for 3 intervals, showing that the time from physician chart open to antibiotic order (doctor to decision time) represents the longest interval of delay. Although not statistically significant, allergy to order set antibiotics was associated with longer time from order to administration (decision to drug time).

1476: INTERVALS OF DELAY IN ANTIBIOTIC ADMINISTRATION FOR EMERGENCY DEPARTMENT PATIENTS WITH SEPSIS

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Robust evidence links timely administration of antibiotics to good outcomes in patients with sepsis. Current guidelines recommend an ambitious goal of antibiotic administration within 1 hour from “time zero”. Little is known about the timing of key processes from Emergency Department (ED) arrival to antibiotic administration for patients with sepsis. Methods: We studied patients presenting to the ED with sepsis (defined as suspected infection and organ dysfunction) at two hospitals with mature sepsis treatment pathways including order sets with preselected antibiotic regimens. We conceptualized the total time from ED arrival to antibiotic administration into 3 intervals. Interval 1: time from arrival to the time a physician opens the patient’s medical record (door to doctor time), Interval 2: time from chart open to entering the antibiotic order (doctor to decision time) and Interval 3: time from order entry to administration of the antibiotic (decision to drug time). We retrospectively abstracted these times from medical records. Because we were specifically interested in how antibiotic allergies might affect delays, we recorded whether patients had allergy to any of the preselected antibiotics. Results: Of 155 patients presenting to the ED with sepsis, 18.7% (28) died during hospitalization. Overall, a mean time of 119.08 minutes (SD 88.8) elapsed between ED arrival and antibiotic administration. The mean time between ED arrival and chart opening by a physician was 16.9 minutes (SD 29.8), the mean time required for physicians to enter an antibiotic order was 68.2 minutes (SD 60.5), followed by another mean time of 40.2 minutes (SD 38.2) to begin drug infusion. Patients with allergy to the preselected antibiotics experienced a longer delay from antibiotic order to administration (36.3 vs 50.1 min, p = 0.09) and longer total delay from chart open to administration (101.6 vs 125.2 min, p = 0.16), but similar time from chart open to placement of antibiotic order (65.3 vs 75.7 min, p = 0.43). Conclusions: In order to reduce ED delays in antibiotic administration for patients with sepsis, we examined the critical phases between arrival and treatment. We report average times for 3 intervals, showing that the time from physician chart open to antibiotic order (doctor to decision time) represents the longest interval of delay. Although not statistically significant, allergy to order set antibiotics was associated with longer time from order to administration (decision to drug time).

1506: RACIAL DIFFERENCES IN PREDICTORS OF TIMELY ANTIBIOTICS AND MORTALITY IN SUSPECTED SEPTIC SHOCK

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Most research demonstrates that black patients suffer nearly double the incidence of severe sepsis than do white patients, although this is not a universal finding. The disparity in sepsis outcomes persists even after controlling for source of infection and underlying chronic illnesses. The mechanism for this racial disparity is unclear. We previously showed that black patients are less likely to receive timely antibiotics compared to white patients. We examined predictors associated with timely antibiotics and mortality in separate models of black and white patients Methods: We analyzed patients from 9 regional hospitals within Carolinas Healthcare System who presented to the Emergency Department with suspected septic shock based on activation of “code sepsis” treatment pathway. We created separate logistic regression models for black and white patients to identify predictors of antibiotic compliance and mortality. Results: Of the 2,928 patients, 2221 (75.8%) were white and 707 (24.1%) were black. White patients were older than black patients but had a lower burden of comorbid conditions. Health insurance payor mix was significantly different between white and black patients, with higher rates of Medicaid in the black subject group and higher rates of Medicare in white patients. On ED presentation, black patients had higher serum lactate but no statistical difference in shock index compared to white patients. In the adjusted analysis for receipt of antibiotics within 1 hour of triage, higher shock index was associated with greater rate of antibiotic timeliness in black patients whereas higher temperature was the physiologic parameter associated with increased antibiotic timeliness in white patients. In the adjusted model for mortality male sex was significantly associated with mortality for black but not white patients. Conclusions: There may be race-specific factors associated with both antibiotic compliance and mortality in suspected septic shock. Clinicians may be responsive to different signals suggesting infection in black versus white patients.