Use of a Hands Free, Instantaneous, Closed-Loop Communication Device Improves Perception of Communication and Workflow Integration in an Academic Teaching Hospital: A Pilot Study.

Efficient and effective communication between providers is critical to quality patient care within a hospital system. Hands free communication devices (HFCD) allow instantaneous, closed-loop communication between physicians and other members of a multidisciplinary team, providing a communication advantage over traditional pager systems. HFCD have been shown to decrease emergency room interruptions, improve nursing communication, improve speed of information flow, and eliminate health care waste. We evaluated the integration of an HFCD with an existing alphanumeric paging system on an acute inpatient medicine service. We conducted a prospective, observational, survey-based study over twenty-four weeks in an academic tertiary care center with attending physicians and residents. Our intervention involved the implementation of an HFCD alongside the existing paging system. Fifty-six pre and post surveys evaluated the perception of improvement in communication and the integration of the HFCD into existing workflow. We saw significant improvements in the ability of an HFCD to help physicians communicate thoughts clearly, communicate thoughts effectively, reach team members, reach ancillary staff, and stay informed about patients. Physicians also reported better workflow integration during admissions, rounds, discharge, and teaching sessions. Qualitative data from post surveys demonstrated that the greatest strengths of the HFCD included the ability to reach colleagues and staff quickly, provide instant access to individuals of the care team, and improve overall communication. Integration of an instantaneous, hands free, closed loop communication system alongside the existing pager system can provide improvements in the perceptions of communication and workflow integration in an academic medicine service. Future studies are needed to correlate these subjective findings with objective measures of quality and safety.

Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts.

BACKGROUND: Best practice alerts (BPAs) provide clinical decision support (CDS) at the point of care to reduce unnecessary blood product transfusions, yet substantial transfusions continue outside of recommended guidelines. OBJECTIVE: To understand why providers order blood transfusions outside of recommended guidelines despite interruptive alerts. DESIGN: Retrospective review. SETTING: Tertiary care hospital. PARTICIPANTS: Inpatient healthcare providers. INTERVENTION: Provider-BPA interaction data were collected from January 2011 to August 2012 from the hospital electronic medical record. MEASUREMENTS: Provider (free-text) responses to blood transfusion BPA prompts were independently reviewed and categorized by 2 licensed physicians, with agreement assessed by χ(2) analysis and kappa scoring. RESULTS: Rationale for overriding blood transfusion BPAs was highly diverse, acute bleeding being the most common (>34%), followed by protocolized behaviors on specialty services (up to 26%), to "symptomatic" anemia (11%-12%). Many providers transfused in anticipation of surgical or procedural intervention (10%-15%) or imminent hospital discharge (2%-5%). Resident physicians represented the majority (55%) of providers interacting with BPAs. CONCLUSION: Providers interacting with BPAs (primarily residents and midlevel providers) often do not have the negotiating power to change ordering behavior. Protocolized behaviors, unlikely to be influenced by BPAs, are among the most commonly cited reasons for transfusing outside of guidelines. Symptomatic anemia is a common, albeit subjective, indication cited for blood transfusion. With a wide swath of individually uncommon rationales for transfusion behavior, secondary use of electronic medical record databases and integrated CDS tools are important to efficiently analyze common practice behaviors.

Cost and turn-around time display decreases inpatient ordering of reference laboratory tests: a time series.

OBJECTIVE: Reference tests, also known as send-out tests, are commonly ordered laboratory tests with variable costs and turn-around times. We aim to examine the effects of displaying reference laboratory costs and turn-around times during computerised physician order entry (CPOE) on inpatient physician ordering behaviour. DESIGN: We conducted a prospective observational study at a tertiary care hospital involving inpatient attending physicians and residents. Physician ordering behaviour was prospectively observed between September 2010 and December 2012. An intervention was implemented to display cost and turn-around time for reference tests within our CPOE. We examined changes in the mean number of monthly physician orders per inpatient day at risk, the mean cost per order, and the average turn-around time per order. RESULTS: After our intervention, the mean number of monthly physician orders per inpatient day at risk decreased by 26% (51 vs 38, p<0.0001) with a decrease in mean cost per order (US$146.50 vs US$134.20, p=0.0004). There were no significant differences in mean turn-around time per order (5.6 vs 5.7 days, p=0.057). A stratified analysis of both cost and turn-around time showed significant decreases in physician ordering. The intervention projected a mean annual savings of US$330 439. Reference test cost and turn-around time variables were poorly correlated (r=0.2). These findings occurred in the setting of non-significant change to physician ordering in a control cohort of non-reference laboratory tests. CONCLUSIONS: Display of reference laboratory cost and turn-around time data during real-time ordering may result in significant decreases in ordering of reference laboratory tests with subsequent cost savings.

Burnout in premedical undergraduate students.

BACKGROUND: There has been growing recognition that medical students, interns, residents and practicing physicians across many specialties are prone to burnout, with recent studies linking high rates of burnout to adverse mental health issues. Little is known about the trajectory and origins of burnout or whether its roots may be traced to earlier in medical training, specifically, during undergraduate studies. Here, the authors surveyed undergraduates at UC San Diego (UCSD) to assess the relationship of burnout to premedical status while controlling for depression severity. METHODS: Undergraduate students at UCSD were invited to participate in a web-based survey, consisting of demographic questions; the Maslach Burnout Inventory Student Survey (MBI-SS), which gauged the three dimensions of burnout; and the nine-item Patient Health Questionnaire (PHQ-9), to assess depression severity. RESULTS: A total of 618 premedical students and 1,441 non-premedical students completed the questionnaire. Premedical students had greater depression severity and emotional exhaustion than non-premedical students, but they also exhibited a greater sense of personal efficacy. The burnout differences were persistent even after adjusting for depression. Also, premedical women and Hispanic students had especially high levels of burnout, although differences between groups became nonsignificant after accounting for depression. CONCLUSIONS: Despite the limitations of using a burnout questionnaire not specifically normed for undergraduates, the unique ethnic characteristics of the sample, and the uncertain response rate, the findings highlight the importance of recognizing the unique strains and mental health disturbances that may be more common among premedical students than non-premedical students. Results also underscore the close relationship between depression and burnout, and point the way for subsequent longitudinal, multi-institutional studies that could help identify opportunities for prevention and intervention.

Depression in Asian-American and Caucasian undergraduate students.

BACKGROUND: Depression is a serious and often under-diagnosed and undertreated mental health problem in college students which may have fatal consequences. Little is known about ethnic differences in prevalence of depression in US college campuses. This study compares depression severity in Asian-American and Caucasian undergraduate students at the University of California San Diego (UCSD). METHODS: Participants completed the nine item Patient Health Questionnaire and key demographic information via an anonymous online questionnaire. RESULTS: Compared to Caucasians, Asian-Americans exhibited significantly elevated levels of depression. Furthermore, Korean-American students were significantly more depressed than Chinese-American, other minority Asian-American, and Caucasian students. In general, females were significantly more depressed than males. Results were upheld when level of acculturation was considered. LIMITATIONS: The demographic breakdown of the student population at UCSD is not representative to that of the nation. CONCLUSIONS: These findings suggest that outreach to female and Asian-American undergraduate students is important and attention to Korean-American undergraduates may be especially worthwhile.

Depression in premedical undergraduates:a cross-sectional survey.

BACKGROUND: Medical students and residents are known to have high rates of depression, a common stress-related challenge that impairs quality of life and job satisfaction and predisposes those affected to general medical illness. Our primary hypothesis was that premedical students would exhibit greater depressive symptoms than nonpremedical students. A secondary aim was to explore the interactions of premedical student status with gender and ethnicity in the context of depression. METHOD: In this cross-sectional study 647 premedical and 1,495 nonpremedical undergraduates at the University of California, San Diego, were surveyed to examine whether seeds of depression can be identified even before formal medical training. Participants completed a series of demographic questions along with the 9-item Patient Health Questionnaire to gauge depression intensity. The survey was made available online for a period of 3 months from March 2009-June 2009. RESULTS: Premedical students were more likely to meet screening criteria suggestive of the presence of major depressive disorder and to exhibit more severe depression than nonpremedical students. Female premedical students exhibited greater depression than female nonpremedical students and males in general. Hispanic premedical students, in particular, had a greater prevalence of depression and greater intensity of depressive symptoms than other premedical students and Hispanic nonpremedical students. No differences were found in current, past, or family history between premedical and nonpremedical students. CONCLUSIONS: These findings underscore the importance of understanding the unique strains and mental health consequences of a premedical curriculum, especially for women and certain minority ethnic populations. A meaningful next step would be a larger study, conducted by several representative university campuses, to confirm these findings; a follow-up of these cohorts could track longitudinal progress. More research must be done to determine the etiology of these findings with the ultimate intention of identifying opportunities for prevention and early intervention, which may provide significant public health payoffs in the long run.