Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care.

STUDY AIM: This study aims to describe the transition-in-care work process for sepsis survivors going from hospitals to home health care (HHC) and identify facilitators and barriers to enable practice change and safe care transitions using a human factors and systems engineering approach. BACKGROUND: Despite high readmission risk for sepsis survivors, the transition-in-care work process from hospitals to HHC has not been described. METHODS: We analyzed semi-structured needs assessment interviews with 24 stakeholders involved in transitioning sepsis survivors from two hospitals and one affiliated HHC agency participating in the parent implementation science study, I-TRANSFER. The qualitative data analysis was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the work process and identify work system elements. RESULTS: We identified 31 tasks characterized as decision making, patient education, communication, information, documentation, and scheduling tasks. Technological and organizational facilitators lacked in HHC compared to the hospitals. Person and organization elements in HHC had the most barriers but few facilitators. Additionally, we identified specific task barriers that could hinder sepsis information transfer from hospitals to HHC. CONCLUSION: This study explored the complex transition-in-care work processes for sepsis survivors going from hospitals to HHC. We identified barriers, facilitators, and critical areas for improvement to enable implementation and ensure safe care transitions. A key finding was the sepsis information transfer deficit, highlighting a critical issue for future study. APPLICATION: We recommend using the SEIPS framework to explore complex healthcare work processes before the implementation of evidence-based interventions.

Social Risk Factors are Associated with Risk for Hospitalization in Home Health Care: A Natural Language Processing Study.

OBJECTIVE: This study aimed to develop a natural language processing (NLP) system that identified social risk factors in home health care (HHC) clinical notes and to examine the association between social risk factors and hospitalization or an emergency department (ED) visit. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: We used standardized assessments and clinical notes from one HHC agency located in the northeastern United States. This included 86,866 episodes of care for 65,593 unique patients. Patients received HHC services between 2015 and 2017. METHODS: Guided by HHC experts, we created a vocabulary of social risk factors that influence hospitalization or ED visit risk in the HHC setting. We then developed an NLP system to automatically identify social risk factors documented in clinical notes. We used an adjusted logistic regression model to examine the association between the NLP-based social risk factors and hospitalization or an ED visit. RESULTS: On the basis of expert consensus, the following social risk factors emerged: Social Environment, Physical Environment, Education and Literacy, Food Insecurity, Access to Care, and Housing and Economic Circumstances. Our NLP system performed "very good" with an F score of 0.91. Approximately 4% of clinical notes (33% episodes of care) documented a social risk factor. The most frequently documented social risk factors were Physical Environment and Social Environment. Except for Housing and Economic Circumstances, all NLP-based social risk factors were associated with higher odds of hospitalization and ED visits. CONCLUSIONS AND IMPLICATIONS: HHC clinicians assess and document social risk factors associated with hospitalizations and ED visits in their clinical notes. Future studies can explore the social risk factors documented in HHC to improve communication across the health care system and to predict patients at risk for being hospitalized or visiting the ED.

Uncovering hidden trends: identifying time trajectories in risk factors documented in clinical notes and predicting hospitalizations and emergency department visits during home health care.

OBJECTIVE: This study aimed to identify temporal risk factor patterns documented in home health care (HHC) clinical notes and examine their association with hospitalizations or emergency department (ED) visits. MATERIALS AND METHODS: Data for 73 350 episodes of care from one large HHC organization were analyzed using dynamic time warping and hierarchical clustering analysis to identify the temporal patterns of risk factors documented in clinical notes. The Omaha System nursing terminology represented risk factors. First, clinical characteristics were compared between clusters. Next, multivariate logistic regression was used to examine the association between clusters and risk for hospitalizations or ED visits. Omaha System domains corresponding to risk factors were analyzed and described in each cluster. RESULTS: Six temporal clusters emerged, showing different patterns in how risk factors were documented over time. Patients with a steep increase in documented risk factors over time had a 3 times higher likelihood of hospitalization or ED visit than patients with no documented risk factors. Most risk factors belonged to the physiological domain, and only a few were in the environmental domain. DISCUSSION: An analysis of risk factor trajectories reflects a patient's evolving health status during a HHC episode. Using standardized nursing terminology, this study provided new insights into the complex temporal dynamics of HHC, which may lead to improved patient outcomes through better treatment and management plans. CONCLUSION: Incorporating temporal patterns in documented risk factors and their clusters into early warning systems may activate interventions to prevent hospitalizations or ED visits in HHC.

The Relationship Benefits of Auto Maintenance and Repair Service: A Case Study of Korea.

This study aimed to empirically examine what effects confidence, social, and economic benefit factors have on continuous relationship orientation through the mediation of service trust, service satisfaction, and customer engagement factors in the auto maintenance and repair service sector. This study carried out a questionnaire survey with 319 customers using auto maintenance and repair service and verified hypotheses. As a result of the analysis, the confidence and social benefits of auto maintenance and repair service affected service trust, while the confidence and economic benefits affected service satisfaction. Service trust did not affect customer engagement or long-term relationship continuity but affected them when it mediated service satisfaction. Consequently, it was revealed that confidence benefit should be consolidated and that professionalism or service quality excellence in maintenance or repair becomes the most important factors to produce customer engagement or long-term relationship continuity in the auto maintenance and repair service. Although it is vital to improve trust or service, it is confirmed that a relationship can be maintained only if the auto maintenance or repair service is satisfactory.

Pancreatic Cancer Related Health Disparities: A Commentary.

We summarize the risk factors that may significantly contribute to racial disparities in pancreatic cancer, which is now the third leading cause of cancer deaths and projected to be second around 2030 in 12 years. For decades, the incidence rate of pancreatic cancer among Blacks has been 30% to 70% higher than other racial groups in the United States and the 5-year survival rate is approximately 5%. Diabetes and obesity have been identified as potentially predisposing factors to pancreatic cancer and both are more common among Blacks. Smoking continues to be one of the most important risk factors for pancreatic cancer and smoking rates are higher among Blacks compared to other racial groups. The overall risk of pancreatic cancer due to changes in DNA is thought to be the same for most racial groups; however, DNA methylation levels have been observed to be significantly different between Blacks and Whites. This finding may underlie the racial disparities in pancreatic cancer. Identification and prevention of these factors may be effective strategies to reduce the high incidence and mortality rates for pancreatic cancer among Blacks.

Dignity Impact as a Primary Outcome Measure for Dignity Therapy.

BACKGROUND: Feasibility of dignity therapy (DT) is well established in palliative care. Evidence of its efficacy, however, has been inconsistent and may stem from DT's primary effects differing from the outcomes measured in previous studies. We proposed that DT effects were in the spiritual domain and created a new outcome measure, Dignity Impact Scale (DIS), from items previously used in a large randomized controlled trial (RCT). OBJECTIVE: The purpose of this secondary analysis study was to examine properties of a new measure of dignity impact. DESIGN: Using the DIS, we conducted reanalysis of posttest data from a large 3-arm, multi-site RCT study. SETTING/PARTICIPANTS: Participants were receiving hospice/palliative care (n = 326, 50.6% female, mean age = 65.1 years, 89.3% white, all with a terminal illness with 6 months or less life expectancy). They had been randomized to standard palliative care (n = 111), client-centered care (n = 107), or DT (n = 108). MEASUREMENT: The 7-item DIS was derived from selected items in a posttest DT Patient Feedback Questionnaire. The DIS had strong internal consistency (α = 0.85). RESULTS: The DT group mean DIS score (21.4 ± 5.0) was significantly higher than the usual care group mean score (17.7 ± 5.5; t = 5.2, df = 216, P < .001) and a client-centered intervention group mean score (17.9 ± 4.9; t = 5.2, df = 213, P < .001). CONCLUSION: We found that, compared to both other groups, patients who received DT reported significantly higher DIS ratings, which is consistent with the DT focus on meaning-making, preparation for death, and life completion tasks. We propose that the DIS be used as the primary outcome measure in evaluating the effects of DT.

Electrogastrography, Near-infrared Spectroscopy, and Acoustics to Measure Gastrointestinal Development in Preterm Babies.

OBJECTIVES: The aim of the study was to obtain objective measures indicative of gastrointestinal maturity using 3 noninvasive technologies. METHODS: Electrogastrography (EGG), abdominal near-infrared spectroscopy (NIRS), and bowel sound/acoustics (AC) monitoring were used simultaneously to obtain physiologic measures of the gastrointestinal system of 18 preterm and 5 term neonates who were tolerating enteral feedings. Measures of EGG slow wave voltage (EGG dominant power) and AC signal amplitude (AC dominant power) were obtained after spectral density analysis. Mean abdominal regional saturations (A-rSO2) were obtained directly from NIRS. The relationship of these 3 measures with postmenstrual age (PMA) was assessed. RESULTS: The results of the 3 methods differed depending on whether the measurements were pre- or postprandial. Postprandial EGG dominant power increases with PMA (r = 0.67, P = 0.003), both pre- and postprandial abdominal NIRS mean regional saturation increase with PMA (r = 0.73, P < 0.001 and r = 0.55, P = 0.009), and postprandial AC dominant power (at 300-500 Hz) increases with PMA (r = -0.48, P = 0.025). CONCLUSIONS: EGG, abdominal NIRS, and AC, whenever used simultaneously, can provide objective and synergistic measures that correlate with PMA. These findings may be helpful in the assessment of feeding readiness because they reveal quantitative measures suggestive of the developmental process of the gut.

Clinical insights for early detection of acute transverse myelitis in the emergency department.

OBJECTIVE: Acute transverse myelitis (ATM) is characterized by motor weakness, sensory changes, and autonomic dysfunction. However, diagnosis of ATM is based on early-stage clinical features only (and clarification of the cause of disease), which are difficult for emergency department (ED) physicians owing to low incidence rates. We performed retrospective analysis of ATM in order to provide clinical insights for early detection. METHODS: Medical records of patients, who were finally diagnosed with ATM from January 2005 to February 2013, were investigated. Data, including demographics, clinical findings, and radiographic findings, were reviewed. RESULTS: Forty-six patients were included in the present study, with a mean age of 43.4 years. Sensory changes were identified in 45 patients (97.8%), motor weakness in 33 patients (71.7%), and autonomic dysfunction in 35 patients (76.1%). Thirty patients (65.2%) showed high signal intensity in T2-weighted magnetic resonance imaging (MRI), with lesions most frequently found in the thoracic level of the spinal cord (56.7%). There were discrepancies between sensory changes and levels of MRI lesions. Thirty-five patients (76.1%) were diagnosed with idiopathic ATM. Initial diagnostic impressions in the ED were herniated intervertebral disc (38.7%), stroke (19.4%), Guillain-Barré syndrome (12.9%), cauda equina syndrome (9.7%), ATM (9.7%), and others (9.7%). CONCLUSION: When a patient presents with motor weakness, sensory changes, or autonomic dysfunction, ATM should be initially considered as a differential diagnosis, unless the ED physician's impression after initial evaluation is clear.

A quantitative analysis of the relation between the clavicular tilt angle and subclavian central venous catheter misplacement.

OBJECTIVE: The aim of the present study was to investigate the relation between shoulder position and subclavian central venous (SCV) catheter misplacement. The shoulder position was estimated using clavicular tilt angle (CTA) values observed on anteroposterior chest X-ray images. METHODS: A retrospective case-control study was conducted on all adult patients who underwent SCV catheterization in the emergency department during a 12-month period. Collected data included patient age, sex, diagnosis, catheterization side, catheter misplacement, and physician's level of experience in catheterization. The CTA and other radiological variables such as the ipsilateral transverse length of the thorax and thickness of the clavicle were investigated. RESULTS: Among all central venous catheterizations (n=1,599), the subclavian route was used 981 times (61.4%). There were 51 misplacements of SCV catheters (5.2%) during the study period. There were no differences in the sex, age, blood pressure, and diagnosis between the two groups. The CTA values were 28.5°±7.3° and 22.6°±6.3° in the misplacement group and control group, respectively (95% confidence interval, 3.6 to 8.1; P<0.001). CONCLUSION: In this study, the CTA was found to be 5.9° larger in the misplacement group than in the control group. Assuming that CTA indicates the shoulder position, our findings suggest that the chance of SCV catheter misplacement may be reduced by avoiding the shoulder elevated.

Carbon monoxide-induced cardiomyopathy.

BACKGROUND: Previous reports demonstrated mechanisms of cardiac toxicity in acute carbon monoxide (CO) poisoning. Still, none established CO-induced cardiomyopathy (CMP) as a clinical entity. The aim of this study is to investigate CO-induced CMP in patients with acute CO poisoning in terms of its epidemiology, clinical characteristics, and prognosis. METHODS AND RESULTS: A retrospective study was conducted on consecutive patients who were diagnosed with acute CO poisoning at the emergency department of Ajou University Hospital during the period of 62 month. Six hundred and twenty-six patients were diagnosed with acute CO poisoning. During the initial echocardiography, 19 patients were abnormal: (1) global hypokinesia/akinesia (n=7), (2) regional wall hypokinesia/akinesia [n=12; takotsubo type (n=6), reverse takotsubo type (n=2), non-specific type (n=4)]. The ejection fraction (EF) was 36.3±13.5% (from 15% to 55%) and less than 45% for 14 patients. In the follow-up echocardiography performed within 12 days after the initial performance, most patients were found to have cardiac wall motion abnormalities, and their EF had returned to normal (ie, EF ≥50%). CONCLUSIONS: CO-induced CMP was identified in 3.04% (n=19) of all patients (n=626). It might not be too critical in acute clinical courses of acute CO poisoning because the prognosis seems favorable. Considering the common factors between CO-induced CMP and takotsubo CMP, myocardial stunning subject to a catecholamine surge most likely plays a central role in the development of CO-induced CMP.

Evaluation of exhaled nitric oxide in acute paraquat poisoning: a pilot study.

BACKGROUND: Fractional exhaled nitric oxide (FENO) is nitric oxide (NO) in the lower airway measured by oral exhalation. FENO can be a useful non-invasive marker for asthma. Paraquat-mediated lung injury can be reflective of an ROS-induced lung injury. We aimed to verify if FENO is a clinical parameter of ROS formation and responsiveness to medical therapies in acute paraquat intoxication. MATERIAL AND METHODS: We recruited 12 patients admitted with acute paraquat poisoning. A portable and noninvasive device called NIOX MINO™ (Aerocrine AB, Solna, Sweden) was used to measure FENO. Measurements were made at the time of hospital admission and at 24, 48, 72, 96, and 120 h after paraquat ingestion. RESULTS: Six out of the total 12 recruited patients had general conditions (e.g. oral pain) that made it difficult for them to exhale with adequate force. Mean plasma paraquat level was 1.4 ± 2.5 g/mL. We found no direct correlation between the paraquat levels (both ingestion amount and plasma concentration) and FENO (initial, maximal, and minimal values). All the measured FENO values were no greater than 20 ppb for the 2 patients who died. FENO did not vary more than 20% from the baseline. Compared to the above findings, FENO measurements were found to be greater than 20 ppb for the patients who survived. FENO tends to reach its peak value at between 50 h and 80 h. CONCLUSIONS: FENO did not predict mortality, and there was no increase of FENO in patients with severe paraquat intoxication.

Enhancement of lipid extraction from marine microalga, Scenedesmus associated with high-pressure homogenization process.

Marine microalga, Scenedesmus sp., which is known to be suitable for biodiesel production because of its high lipid content, was subjected to the conventional Folch method of lipid extraction combined with high-pressure homogenization pretreatment process at 1200 psi and 35°C. Algal lipid yield was about 24.9% through this process, whereas only 19.8% lipid can be obtained by following a conventional lipid extraction procedure using the solvent, chloroform:methanol (2:1, v/v). Present approach requires 30 min process time and a moderate working temperature of 35°C as compared to the conventional extraction method which usually requires >5 hrs and 65°C temperature. It was found that this combined extraction process followed second-order reaction kinetics, which means most of the cellular lipids were extracted during initial periods of extraction, mostly within 30 min. In contrast, during the conventional extraction process, the cellular lipids were slowly and continuously extracted for >5 hrs by following first-order kinetics. Confocal and scanning electron microscopy revealed altered texture of algal biomass pretreated with high-pressure homogenization. These results clearly demonstrate that the Folch method coupled with high-pressure homogenization pretreatment can easily destruct the rigid cell walls of microalgae and release the intact lipids, with minimized extraction time and temperature, both of which are essential for maintaining good quality of the lipids for biodiesel production.

The effect of ultrasonificated extracts of Spirulina maxima on the anticancer activity.

The effect of ultrasonic extraction on extraction yields, cytotoxicity, and anticancer activity of Spirulina maxima was investigated in this study. Optimal extraction conditions were determined as 60 kHz frequency at 60°C for 30 min with 120 W intensity, which resulted in 19.3% of extraction yields and 19.1% of cytotoxicity on normal human cells. Yields from conventional water and ethanol extraction were 15.8% at 100°C and 8.3% at 80°C, respectively. It was found that the extracts obtained by ultrasonic extraction process selectively inhibited the digestive-related cancer cell lines, such as human stomach cancer cells, having 89% of the highest inhibition ratio and 4.5 of the highest selectivity. In adding 0.5 mg/mL of the extract, human promyelocytic leukemia cells' cell differentiation was increased 1.72 times over that of the control. Expression level of B cell lymphoma-2 from Hep3B cell was also effectively suppressed by the extract obtained at 60 kHz and 60°C, leading to the inhibition of the early step of carcinogenesis. This work suggests that anticancer activity of the extracts is due to water-soluble polysaccharides rather than proteins and is further supported by the result that the ultrasonification extraction process can efficiently extract relatively intact polysaccharides rather than digesting the proteins in S. maxima by matrix assisted laser desorption ionization-time of flight and high performance size exclusion chromatography chromatogram analyses. Therefore, ultrasonic extraction increases both extraction yield and the biological activity of S. maxima extracts, which might be useful as an alternative natural anticancer agent in the medical and food industries.

A robust current pattern for the detection of intraventricular hemorrhage in neonates using electrical impedance tomography.

We compared two 16-electrode electrical impedance tomography (EIT) current patterns on their ability to reconstruct and quantify small amounts of bleeding inside a neonatal human head using both simulated and phantom data. The current patterns used were an adjacent injection RING pattern (with electrodes located equidistantly on the equator of a sphere) and an EEG current pattern based on the 10-20 EEG electrode layout. Structures mimicking electrically important structures in the infant skull were included in a spherical numerical forward model and their effects on reconstructions were determined. The EEG pattern was found to be a better topology to localize and quantify anomalies within lateral ventricular regions. The RING electrode pattern could not reconstruct anomaly location well, as it could not distinguish different axial positions. The quantification accuracy of the RING pattern was as good as the EEG pattern in noise-free environments. However, the EEG pattern showed better quantification ability than the RING pattern when noise was added. The performance of the EEG pattern improved further with respect to the RING pattern when a fontanel was included in forward models. Significantly better resolution and contrast of reconstructed anomalies was achieved when generated from a model containing such an opening and 50 dB added noise. The EEG method was further applied to reconstruct data from a realistic neonatal head model. Overall, acceptable reconstructions and quantification results were obtained using this model and the homogeneous spherical forward model.

Normalization of a spatially variant image reconstruction problem in electrical impedance tomography using system blurring properties.

The electrical impedance tomography (EIT) image reconstruction problem is ill posed and spatially variant. Because of the problem's ill-posed nature, small amounts of measurement noise can corrupt reconstructed images. The problem must be regularized to reduce image artifacts. In this paper, we focus on the spatially variant characteristics of the problem. Correcting errors due to spatial variance should improve reconstruction accuracy. In this paper, we present methods to normalize the spatially variant image reconstruction problem by equalizing the point spread function (PSF). In order to equalize the PSF, we used the reconstruction blurring properties obtained from the sensitivity matrix. We compared three mathematical normalization schemes: pixel-wise scaling (PWS), weighted pseudo-inversion (WPI) and weighted minimum norm method (WMNM) to equalize images. The quantity index (QI), defined as the integral of pixel values of an EIT conductivity image, was considered in investigating spatial variance. The QI values along with reconstructed images are presented for cases of two-dimensional full array and hemiarray electrode topologies. We found that a spatially invariant QI could be obtained by applying normalization methods based on equalization of the PSF using conventional regularized reconstruction methods such as truncated singular value decomposition (TSVD) and WMNM. We found that WMNM normalization applied to WMNM regularized reconstruction was the best of the methods tested overall, for both hemiarray and full array electrode topologies.