Nurse-focused ultrasound-guided IV program improves core emergency department process measures.

INTRODUCTION: Ultrasound-guided peripheral IV catheter (USGIV) insertion is as an effective procedure to establish access in patients with difficult intravenous access (DIVA), a condition frequently encountered in the Emergency Department (ED). This study describes a DIVA quality improvement program focusing on rapid identification of DIVA patients and emergency nurse USGIV training and evaluates its impact on overall frequency of USGIV use and process measures related to quality of patient care. METHODS: This is a retrospective cohort study of patients over 18 years of age, presenting to a single, tertiary care hospital between September 1, 2018 and September 30, 2020. Difference-in-difference analysis was used to compare ED process measures pre- and post-implementation of the DIVA Program, and multivariate logistic regression was used to identify associations between patient characteristics and difficult IV access. RESULTS: The frequency of ED encounters associated with USGIV placement more than doubled post-implementation of the DIVA Program, rising from 606 to 1323. There were improved covariate-adjusted time estimates of core ED process measures for encounters associated with USGIV placement post-implementation, including decreases in time to CT with contrast from 4.8 h (95% CI = 4.4-5.2) to 4.1 h (95% CI = 3.8-4.4), pain medications from 2.4 h (95% CI = 2.1-2.6) to 1.8 h (95% CI = 1.6-2.0), IV antibiotics from 3.0 h (95% CI = 2.4-3.7) to 2.1 h (95% CI = 1.5-2.6), and ED length of stay from 6.4 h (95% CI = 6.2-6.6) to 6.0 h (95% CI = 5.9-6.2). CONCLUSION: A nurse-focused quality improvement program focused on teaching and promoting USGIV as a modality for managing difficult IV access was associated with increases in USGIV placement and improvements in core process measures related to quality of patient care.

From Battles to Burnout: Investigating the Role of Interphysician Conflict in Physician Burnout.

PURPOSE: Despite the recognized importance of collaborative communication among physicians, conflict at transitions of care remains a pervasive issue. Recent work has underscored how poor communication can undermine patient safety and organizational efficiency, yet little is known about how interphysician conflict (I-PC) impacts the physicians forced to navigate these tensions. The goal of this study was to explore the social processes and interpersonal interactions surrounding I-PC and their impact, using conversations regarding admission between internal medicine (IM) and emergency medicine (EM) as a lens to explore I-PC in clinical practice. METHOD: The authors used constructivist grounded theory to explore the interpersonal and social dynamics of I-PC. They used purposive sampling to recruit participants, including EM resident and attending physicians and IM attending physicians. The authors conducted hour-long, semistructured interviews between June and October 2020 using the Zoom video conferencing platform. Interviews were coded in 3 phases: initial line-by-line coding, focused coding, and recording. Constant comparative analysis was used to refine emerging codes, and the interview guide was iteratively updated. RESULTS: The authors interviewed 18 residents and attending physicians about how engaging in I-PC led to both personal and professional harm. Specifically, physicians described how I-PC resulted in emotional distress, demoralization, diminished sense of professional attributes, and job dissatisfaction. Participants also described how emotional residue attached to past I-PC events primed the workplace for future conflict. CONCLUSIONS: I-PC may represent a serious yet underrecognized source of harm, not only to patient safety but also to physician well-being. Participants described both the personal and professional consequences of I-PC, which align with the core tenets of burnout. Burnout is a well-established threat to the physician workforce, but unlike many other contributors to burnout, I-PC may be modifiable through improved education that equips physicians with the skills to navigate I-PC throughout their careers.

Performance of peripheral catheters inserted with ultrasound guidance versus landmark technique after a simulation-based mastery learning intervention.

PROBLEM: Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is an effective method to gain vascular access in patients with difficult intravenous access (DIVA). While USGPIV success rates are reported to be high, some studies have reported a concerning incidence of USGPIV premature failures. AIMS: The purpose of this study was to compare differences in USGPIV and landmark peripheral intravenous catheter (PIV) utilization and failure following a hospital-wide USGPIV training program for nurses. METHODS: The authors performed a retrospective, electronic medical record review of all USGPIVs and PIVs inserted at a tertiary, urban, academic medical center from September 1, 2018, through September 30, 2019. The primary outcome was differences between USGPIV and PIV time to failure. RESULTS: A total of 43,470 short peripheral intravenous catheters (PIVCs) were inserted in 23,713 patients. Of these, 7972 (16.8%) were USGPIV. At 30 days of follow-up, for PIVCs with an indication for removal documented, USGPIVs had higher Kaplan-Meier survival probabilities than PIVs (p < 0.001). CONCLUSIONS: The use of simulation-based mastery associated with USGPIVs, demonstrated lower failure rates than standard PIVs after 2 days and USGPIVs exhibited improved survival rates in patients with DIVA. These findings suggest that rigorous simulation-based insertion training demonstrates improved USGPIV survival when compared to traditional PIVCs. SBML is an extremely useful tool to ensure appropriately trained clinicians acquire the necessary knowledge and skillset to improve USGPIV outcomes.

Simulation-Based Mastery Learning Improves Ultrasound-Guided Peripheral Intravenous Catheter Insertion Skills of Practicing Nurses.

INTRODUCTION: Difficult intravenous (IV) access (DIVA) is frequently encountered in the hospital setting. Ultrasound-guided peripheral IV catheter (USGPIV) insertion has emerged as an effective procedure to establish access in patients with DIVA. Despite the increased use of USGPIV, little is known about the optimal training paradigms for bedside nurses. Therefore, we developed and evaluated a novel, sustainable, USGPIV simulation-based mastery learning (SBML) curriculum for nurses. METHODS: This is a prospective cohort study of an USGPIV SBML training program for bedside nurses over a 12-month period. We evaluated skills and self-confidence before and after training and measured the proportion of the nurses achieving independent, proctor, and instructor status. Procedure logs and surveys were used to explore the nurse experience and utilization of USGPIV on real patients with DIVA 3 months after the intervention. RESULTS: Two hundred thirty-eight nurses enrolled in the study. The USGPIV skill checklist scores increased from median of 6.0 [interquartile range = 4.0-9.0 (pretest) to 29.0, interquartile range = 28-30 (posttest), P < 0.001]. The USGPIV confidence improved from before (mean = 2.32, SD = 1.17) to after (mean = 3.85, SD = 0.73, P < 0.001) training (5-point Likert scale). Sixty-two percent of the nurses enrolled achieved independent status, 47.5% became proctors, and 11.3% course trainers. At 3-month posttraining, the nurses had attempted a mean of 35.6 USGPIV insertions with an 89.5% success rate. CONCLUSIONS: This novel USGPIV SBML curriculum improves nurses' insertion skills, self-confidence, and progresses patient care through USGPIV insertions on hospitalized patients with DIVA.

Ultrasound-Guided Peripheral Intravenous Catheter Insertion Training Reduces Use of Midline Catheters in Hospitalized Patients With Difficult Intravenous Access.

OBJECTIVES: Difficult intravenous (IV) access (DIVA) is a prevalent condition in the hospital setting and increases utilization of midline catheters (MCs) and peripherally inserted central catheters (PICCs). Ultrasound-guided peripheral intravenous (USGPIV) insertion is effective at establishing intravenous access in DIVA but remains understudied in the inpatient setting. We evaluated the effect of an USGPIV simulation-based mastery learning (SBML) curriculum for nurses on MC and PICC utilization for hospitalized patients. METHODS: We performed a quasi-experimental observational study. We trained nurses across all inpatient units at a large tertiary care hospital. We queried the electronic medical record to compare PICC and MC utilization for patients with DIVA during 3 periods: before USGPIV SBML training (control), during pilot testing of the intervention, and during the SBML intervention. To account for variations in insertion practices over time, we performed an interrupted time series (ITS) analysis between 2 periods, the combined control and pilot periods and the intervention period. RESULTS: One hundred forty-eight nurses completed USGPIV SBML training. Midline catheters inserted monthly per 1000 patient-days for DIVA decreased significantly from 1.86 ± 0.51 (control) to 2.31 ± 0.28 (pilot) to 1.33 ± 0.51 (intervention; P = 0.001). The ITS analysis indicated a significant intervention effect (P < 0.001). Peripherally inserted central catheters inserted monthly per 1000 patient-days for DIVA also significantly decreased over the study periods; however, the ITS failed to show an intervention effect as PICC insertions were already decreasing during the control period. CONCLUSIONS: A hospital-wide USGPIV SBML curriculum for inpatient nurses was associated with a significant reduction in MCs inserted for DIVA.

Who's on your team? Specialty identity and inter-physician conflict during admissions.

PURPOSE: Despite the implementation of professionalism curricula and standardised communication tools, inter-physician conflict persists. In particular, the interface between emergency medicine (EM) and internal medicine (IM) has long been recognised as a source of conflict. The social nuances of this conflict remain underexplored, limiting educators' ability to comprehensively address these issues in the clinical learning environment. Thus, the authors explored EM and IM physicians' experiences with negotiating hospital admissions to better understand the social dynamics that contribute to inter-physician conflict and provide foundational guidance for communication best practices. METHODS: Using a constructivist grounded theory (CGT) approach, the authors conducted 18 semi-structured interviews between June and October 2020 with EM and IM physicians involved in conversations regarding admissions (CRAs). They asked participants to describe the social exchanges that influenced these conversations and to reflect on their experiences with inter-physician conflict. Data collection and analysis occurred iteratively. The relationships between the codes were discussed by the research team with the goal of developing conceptual connections between the emergent themes. RESULTS: Participants described how their approaches to CRAs were shaped by their specialty identity, and how allegiance to members of their group contributed to interpersonal conflict. This conflict was further promoted by a mutual sense of disempowerment within the organisation, misaligned expectations, and a desire to promote their group's prerogatives. Conflict was mitigated when patient care experiences fostered cross-specialty team formation and collaboration that dissolved traditional group boundaries. CONCLUSIONS: Conflict between EM and IM physicians during CRAs was primed by participants' specialty identities, their power struggles within the broader organisation, and their sense of duty to their own specialty. However, formation of collaborative inter-specialty physician teams and expansion of identity to include colleagues from other specialties can mitigate inter-physician conflict.

Ischemic ECG Pattern Recognition to Facilitate Interpretation While Task Switching: A Parallel Curriculum.

Introduction: Interruptions are an inevitable part of working as an emergency physician, yet these can increase cognitive load and precipitate medical error. Emergency physicians learn to balance these responsibilities using a process called task switching. Yet residents have little exposure to exercises that purposefully integrate task switching during their training. We addressed this gap by exposing emergency medicine (EM) trainees to task-switching events in the form of critical ECG interpretation while they were engaged in concurrent, parallel activities. Methods: The curriculum was carried out in three phases. First, 12 PGY 2 residents engaged in a small-group session testing their baseline confidence and ECG interpretation skills. The second phase was longitudinal: During concurrent educational activities, investigators interrupted tasks and asked trainees to interpret ECGs in 10 seconds or less. The curriculum's final phase was used to review the ECGs and answer any questions. Results: Confidence and percentage of correct interpretations were compared from phase 1 to phase 2. Participants showed improved confidence (M = 2.5, SD = 0.6, to M = 2.9, SD = 0.6; p = .02; 5-point Likert scale) and increased mean percent correct (M = 0.7, SD = 0.1, to M = 0.8, SD = 0.1; p = .01) following the curriculum. Discussion: Our curriculum provides a pragmatic, reproducible approach to enhancing critical ECG interpretation with task switching in a way that mirrors the EM practice environment, promoting a reduction of cognitive load and highlighting the skills learners will need as they develop expertise.

Difficult intravenous access in the emergency department: Performance and impact of ultrasound-guided IV insertion performed by nurses.

BACKGROUND: Difficult intravenous access (DIVA) is a common problem in Emergency Departments (EDs), yet the prevalence and clinical impact of this condition is poorly understood. Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is a successful modality for obtaining intravenous (IV) access in patients with DIVA. OBJECTIVES: We aimed to describe the prevalence of DIVA, explore how DIVA affects delivery of care, and determine if nurse insertion of USGPIV improves care delays among patients with DIVA. METHODS: We retrospectively queried the electronic medical record for all ED patients who had a peripheral IV (PIV) inserted at a tertiary academic medical center from 2015 to 2017. We categorized patients as having DIVA if they required ≥3 PIV attempts or an USGPIV. We compared metrics for care delivery including time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED length of stay (LOS) between patients with and without DIVA. We also compared these metrics in patients with DIVA with a physician-inserted USGPIV versus those with a nurse-inserted USGPIV. RESULTS: A total of 147,260 patients were evaluated during the study period. Of these, 13,192 (8.9%) met criteria for DIVA. Patients with DIVA encountered statistically significant delays in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients without DIVA (all p < 0.001). Patients with nurse-inserted USGPIVs also had statistically significant improvements in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients with physician-inserted USGPIVs (all p < 0.001). CONCLUSION: DIVA affects many ED patients and leads to delays in PIV access-related care. Nurse insertion of USGPIVs improves care in patients with DIVA.

A mixed-methods needs assessment of adult diabetes mellitus (type II) and hypertension care in Toledo, Belize.

BACKGROUND: Non-communicable diseases, including diabetes mellitus and hypertension, continue to disproportionately burden low- and middle-income countries. However, little research has been done to establish current practices and management of chronic disease in these settings. The objective of this study was to examine current clinical management and identify potential gaps in care of patients with diabetes mellitus and hypertension in the district of Toledo, Belize. METHODS: The study used a mixed methodology to assess current practices and identify gaps in diabetes mellitus and hypertension care. One hundred and twenty charts of the general clinic population were reviewed to establish disease epidemiology. One hundred and seventy-eight diabetic and hypertensive charts were reviewed to assess current practices. Twenty providers completed questionnaires regarding diabetes mellitus and hypertension management. Twenty-five individuals with diabetes mellitus and/or hypertension answered a questionnaire and in-depth interview. RESULTS: The prevalence of diabetes mellitus and hypertension was 12%. Approximately 51% (n = 43) of patients with hypertension were at blood pressure goal and 26% (n = 21) diabetic patients were at glycemic goal based on current guidelines. Of the patients with uncontrolled diabetes, 49% (n = 29) were on two oral agents and only 10% (n = 6) were on insulin. Providers stated that barriers to appropriate management include concerns prescribing insulin and patient health literacy. Patients demonstrated a general understanding of the concept of chronic illness, however lacked specific knowledge regarding disease processes and self-management strategies. CONCLUSIONS: This study provides an initial overview of diabetes mellitus and hypertension management in a diverse patient population in rural Belize. Results indicate areas for future investigation and possible intervention, including barriers to insulin use and opportunities for lifestyle-specific disease education for patients.

A randomized controlled cross-over trial and cost analysis comparing endoscopic ultrasound fine needle aspiration and fine needle biopsy.

BACKGROUND AND STUDY AIMS: Techniques to optimize endoscopic ultrasound-guided tissue acquisition (EUS-TA) in a variety of lesion types have not yet been established. The primary aim of this study was to compare the diagnostic yield (DY) of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) to endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) for pancreatic and non-pancreatic masses. PATIENTS AND METHODS: Consecutive patients referred for EUS-TA underwent randomization to EUS-FNA or EUS-FNB at four tertiary-care medical centers. A maximum of three passes were allowed for the initial method of EUS-TA and patients were crossed over to the other arm based on on-site specimen adequacy. RESULTS: A total of 140 patients were enrolled. The overall DY was significantly higher with specimens obtained by EUS-FNB compared to EUS-FNA (90.0 % vs. 67.1 %, P = 0.002). While there was no difference in the DY between the two groups for pancreatic masses (FNB: 91.7 % vs. FNA: 78.4 %, P = 0.19), the DY of EUS-FNB was higher than the EUS-FNA for non-pancreatic lesions (88.2 % vs. 54.5 %, P = 0.006). Specimen adequacy was higher for EUS-FNB compared to EUS-FNA for all lesions (P = 0.006). There was a significant rescue effect of crossover from failed FNA to FNB in 27 out of 28 cases (96.5 %, P = 0.0003). Decision analysis showed that the strategy of EUS-FNB was cost saving compared to EUS-FNA over a wide range of cost and outcome probabilities. CONCLUSIONS: RESULTS of this RCT and decision analysis demonstrate superior DY and specimen adequacy for solid mass lesions sampled by EUS-FNB.

Identification of human enteric pathogens in gull feces at Southwestern Lake Michigan bathing beaches.

Ring-billed (Larus delawarensis Ord, 1815) and herring (Larus argentatus Pontoppidan, 1763) gulls are predominant species of shorebirds in coastal areas. Gulls contribute to the fecal indicator burden in beach sands, which, once transported to bathing waters, may result in water quality failures. The importance of these contamination sources must not be overlooked when considering the impact of poor bathing water quality on human health. This study examined the occurrence of human enteric pathogens in gull populations at Racine, Wisconsin. For 12 weeks in 2004 and 2005, and 7 weeks in 2006, 724 gull fecal samples were examined for pathogen occurrence on traditional selective media (BBL CHROMagar-Salmonella, Remel Campy-BAP, 7% horse blood agar) or through the use of novel isolation techniques (Campylobacter, EC FP5-funded CAMPYCHECK Project), and confirmed using polymerase chain reaction (PCR) for pathogens commonly harbored in gulls. An additional 226 gull fecal samples, collected in the same 12-week period in 2004, from a beach in Milwaukee, Wisconsin, were evaluated with standard microbiological methods and PCR. Five isolates of Salmonella (0.7%), 162 (22.7%) isolates of Campylobacter, 3 isolates of Aeromonas hydrophila group 2 (0.4%), and 28 isolates of Plesiomonas shigelloides (3.9%) were noted from the Racine beach. No occurrences of Salmonella and 3 isolates of Campylobacter (0.4%) were found at the Milwaukee beach. A subset of the 2004 samples was also examined for Giardia and Cryptosporidium and was found to be negative. Information as to the occurrence of human pathogens in beach ecosystems is essential to design further studies assessing human health risk and to determine the parameters influencing the fate and transport of pathogens in the nearshore environment.