The Utility of Dot Phrases and SmartPhrases in Improving Physician Documentation of Interpreter Use.

Background: Patients with limited English proficiency (LEP) experience significant healthcare disparities. Clinicians are responsible for using and documenting their use of certified interpreters for patient encounters when appropriate. However, the data on interpreter use documentation in the emergency department (ED) is limited and variable. We sought to assess the effects of dot phrase and SmartPhrase implementation in an adult ED on the rates of documentation of interpreter use. Methods: We conducted an anonymous survey asking emergency clinicians to self-report documentation of interpreter use. We also retrospectively reviewed documentation of interpreter- services use in ED charts at three time points: 1) pre-intervention baseline; 2) post-implementation of a clinician-driven dot phrase shortcut; and 3) post-implementation of a SmartPhrase. Results: Most emergency clinicians reported using an interpreter "almost always" or "often." Our manual audit revealed that at baseline, interpreter use was documented in 35% of the initial clinician note, 4% of reassessments, and 0% of procedure notes; 52% of discharge instructions were written in the patients' preferred languages. After implementation of the dot phrase and SmartPhrase, respectively, rates of interpreter-use documentation improved to 43% and 97% of initial clinician notes, 9% and 6% of reassessments, and 5% and 35% of procedure notes, with 62% and 64% of discharge instructions written in the patients' preferred languages. Conclusion: There was a discrepancy between reported rates of interpreter use and interpreter-use documentation rates. The latter increased with the implementation of a clinician-driven dot phrase and then a SmartPhrase built into the notes. Ensuring accurate documentation of interpreter use is an impactful step in language equity for LEP patients.

Compass for antibiotic stewardship: using a digital tool to improve guideline adherence and drive clinician behaviour for appendicitis treatment in the emergency department.

BACKGROUND: Antibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like appendicitis is common. At baseline, 75% of appendicitis cases at our institution received broad-spectrum ertapenem rather than the recommended narrower-spectrum ceftriaxone/metronidazole combination. We aimed to improve antibiotic stewardship by identifying barriers to guideline adherence and redesigning our appendicitis antibiotic guideline. METHODS: Using the 'Fit between Individuals, Task and Technology (FITT)' framework, we identified barriers that preventclinicians from adhering to guidelines. We reformatted a clinical guideline and disseminated it using our ED's clinical decision support system (CDSS), E*Drive. Next, we examined E*Drive's user data and clinician surveys to assess utilisation and satisfaction. Finally, we conducted a retrospective chart review to measure clinician behaviour change in antibiotic prescription for appendicitis treatment. RESULTS: Data demonstrated an upward trend in the number of monthly users of E*Drive from 1 April 2021 to 30 April 2022, with an average increase of 46 users per month. Our clinician survey results demonstrated that >95% of users strongly agree/agree that E*Drive improves access to clinical information, makes their job more efficient and that E*Drive is easy to access and navigate, with a Net Promoter Score increase from 26.0 to 78.3. 69.4% of patients treated for appendicitis in the post-intervention group received antibiotics concordant with our institutional guideline compared with 20.0% in the pre-intervention group (OR=9.07, 95% CI (3.84 to 21.41)). CONCLUSION: Antibiotic stewardship can be improved by ensuring clinicians have access to convenient and up-to-date guidelines through clinical decision support systems. The FITT model can help guide projects by identifying individual, task and technology barriers. Sustained adherence to clinical guidelines through simplification of guideline content is a potentially powerful tool to influence clinician behaviour in the ED.

Designing clinical guidelines that improve access and satisfaction in the emergency department.

Clinical guidelines are evidence-based clinician decision-support tools that improve health outcomes, reduce patient harm, and decrease healthcare costs, but are often underused in emergency departments (EDs). This article describes a replicable, evidence-based design-thinking approach to developing best practices for guideline design that improves clinical satisfaction and usage. We used a 5-step process to enhance guideline usability in our ED. First, we conducted end-user interviews to identify barriers to guideline usage. Second, we reviewed the literature to identify key principles in guideline design. Third, we applied our findings to create a standardized guideline format, incorporating rapid cycle learning and iterative improvements. Fourth, we ensured the clinical validity of our updated guidelines by using a rigorous process for peer review. Lastly, we evaluated the impact of our guideline conversion process by tracking clinical guidelines access per day from October 2020 to January 2022. Our end-user interviews and review of the design literature revealed several barriers to guideline use, including lack of readability, design inconsistencies, and guideline complexity. Although our previous clinical guideline system averaged 0.13 users per day, >43 users per day accessed the clinical guidelines on our new digital platform in January 2022, representing an increase in access and use exceeding 33,000%. Our replicable process using open-access resources increased clinician access to and satisfaction with clinical guidelines in our ED. Design-thinking and use of low-cost technology can significantly improve clinical guideline visibility and has the potential to increase guideline use.

Building Back Better: Applying Lessons from the COVID-19 Pandemic to Expand Critical Information Access.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic generated an unprecedented volume of evolving clinical guidelines that strained existing clinical information systems and necessitated rapid innovation in emergency departments (EDs). OBJECTIVES: Our team aimed to harness new COVID-19-related reliance on digital clinical support tools to re-envision how all clinical guidelines are stored and accessed in our ED. METHODS: We used a design-thinking approach including empathizing, defining the problem, ideating, prototyping, and testing to develop a low-cost, homegrown clinical information hub: E*Drive. To measure impact, we compared web traffic on E*Drive to our legacy cloud-based folder system and conducted a survey of end-users using a validated health technology utilization instrument. RESULTS: Our final product, E*Drive, is a centralized clinical information hub storing everything from clinical guidelines to discharge resources. Clinical guidelines are standardized and housed within the high-traffic E*Drive platform to increase accessibility. Since launch, E*Drive has averaged 84 unique weekly users, compared with less than one weekly user on the legacy system. We surveyed 52 clinicians for a total response rate of 47%. Prior to the E*Drive rollout, 12.5% of ED clinicians felt confident accessing clinical information on the legacy system, whereas 76.6% of ED clinicians felt they could more easily access clinical information using E*Drive. CONCLUSION: The COVID pandemic revealed vulnerabilities within our information dissemination system and presented an opportunity to improve clinical information delivery. Centralized web-based clinical information hubs designed around the clinician end-user experience can increase clinical guideline access in the ED.

Resident experience of abuse and harassment in emergency medicine: ten years later.

BACKGROUND: In 1995, a Society for Academic Emergency Medicine in-service survey reported high rates of verbal and physical abuse experienced by Emergency Medicine (EM) residents. We sought to determine the prevalence of abuse and harassment 10 years later to bring attention to these issues and determine if there has been a change in the prevalence of abuse over this time period. OBJECTIVES: To determine the prevalence of abuse and harassment in a sample of EM residencies. METHODS: We conducted a cross-section survey of EM residents from 10 residencies. EM residents were asked about their experience with verbal abuse, verbal threats, physical threats, physical attacks, sexual harassment, and racial harassment; and by whom. The primary outcome of the study was the prevalence of abuse and harassment as reported by EM residents. RESULTS: There were 196 of 380 residents (52%) who completed the survey. The prevalence of any type of abuse experienced was 91%; 86% of residents experienced verbal abuse, 65% verbal threats, 50% physical threats, 26% physical attacks, 23% sexual harassment, and 26% racial harassment. Women were more likely than men to encounter sexual harassment (37% [38/102] vs. 8% [7/92]; p < 0.001). Racial harassment was not limited to minorities (23% [16/60] for Caucasians vs. 26% [29/126] for non-Caucasians; p = 0.59). Senior residents were more likely to have encountered verbal and physical abuse. Only 12% of residents formally reported the abuse they experienced. CONCLUSION: Abuse and harassment during EM residency continues to be commonplace and is underreported.

Perinatal exposure to delta(9)-tetrahydrocannabinol alters heroin-induced place conditioning and fos-immunoreactivity.

In the present study, the effects of perinatal exposure to Delta(9)-tetrahydrocannabinol (THC) on heroin-induced place conditioning and Fos-immunoreactivity (Fos-IR) were examined. Male albino Wistar rats (N=104) were pretreated with vehicle (n=52) or 5 mg/kg THC (n=52) from postnatal days 4 through 14. At approximately 8 weeks of age, 72 rats were divided into six equal groups (n=12 per group) and injected subcutaneously (s.c.) with vehicle, 0.5, or 2.0 mg/kg heroin and tested in an unbiased two-compartment place conditioning task. In vehicle-pretreated rats, 2.0 mg/kg but not 0.5 mg/kg heroin produced a significant place preference. Perinatal THC exposure significantly enhanced the rewarding properties of both doses of heroin. In the second experiment, 32 rats were divided into four equal groups (n=8 per group) and injected with vehicle or 0.5 mg/kg heroin s.c. and perfused 2-h later. Fos-IR was examined in several brain regions directly or indirectly involved in reward. Acute administration of heroin in vehicle pretreated rats increased Fos-IR in the central, medial, and dorsomedial caudate putamen (CPu), nucleus accumbens (NAC, core and shell regions), lateral septum, islands of Calleja-major (ICjM), bed nucleus of the stria terminalis (BNST), central nucleus of the amygdala (CEA), dorsolateral and dorsomedial periaqueductal gray (PAG), ventral tegmental area (VTA), Edinger-Westphal nucleus (EW). Perinatal THC exposure significantly increased heroin-induced Fos-IR in the dorsomedial CPu. Conversely, perinatal THC exposure reduced heroin-induced Fos-IR in the NAC (shell), BNST, CEA, dorsolateral and lateral PAG, VTA, and EW. The present study demonstrates an increase in the rewarding properties of heroin following exposure to THC at an early age and provides new evidence regarding possible neural correlates underlying this behavioral alteration. Neuropsychopharmacology (2006) 31, 58-69. doi:10.1038/sj.npp.1300770; published online 25 May 2005.

Chronic cannabinoid exposure produces lasting memory impairment and increased anxiety in adolescent but not adult rats.

Although many studies have examined the acute behavioural effects of cannabinoids in rodents, few have examined the lasting effects of cannabinoids at different developmental ages. This study compared lasting effects of cannabinoid exposure occurring in adolescence to that occurring in early adulthood. Forty, 30-day old (adolescent) and 18, 56-day old (adult) female albino Wistar rats were injected with vehicle or incremental doses of the cannabinoid receptor agonist (-)-cis-3-[2-hydroxy-4-(1,1-dimethylheptyl)phenyl]-trans-4-(3-hydroxypropyl) cyclohexanol (CP 55,940) once per day for 21 consecutive days (150, 200 and 300 microg/kg i.p. for 3, 8 and 10 days, respectively). Following a 21-day drug-free period, working memory was assessed using an object recognition task. Locomotor activity was also measured in the object recognition apparatus via a ceiling-mounted passive infrared sensor. Three days later, anxiety was assessed using a social interaction test. In the object recognition task, significantly poorer working memory was observed in the adolescent but not adult CP 55,940-treated rats. Adolescent, but not adult CP 55,940-treated rats, also exhibited a significant decrease in social interaction with a novel conspecific. These results suggest that chronic exposure to a cannabinoid receptor agonist well after the immediate postnatal period, but before reaching sexual maturity, can lead to increased anxiety and a lasting impairment of working memory.

The cannabinoid receptor antagonist SR 141716 attenuates overfeeding induced by systemic or intracranial morphine.

RATIONALE: Considerable interplay exists between the brain's opioid and cannabinoid systems. These systems are both involved in the control of appetite and research supports the notion that the opioid system modulates the role of the cannabinoid system on appetite. However, the ability of the cannabinoid system to modulate the opioid system's control over appetite has not been well studied. OBJECTIVES: The present study examined the role of cannabinoid CB(1) receptors in the control of opioid-induced feeding, and sought to identify specific brain regions underlying this role. METHODS: After being habituated to the test environment and injection procedure, sated rats were injected with the cannabinoid CB(1) receptor antagonist SR 141716 (0.03-3.0 mg/kg, IP). Thirty minutes later, morphine or its vehicle were administered systemically (2.5 mg/kg SC, experiments 1 and 2) or intracranially into the nucleus accumbens (nAcc, experiment 3) or paraventricular nucleus of the hypothalamus (PVN, experiment 4). Food intake and locomotor activity was then recorded for 120 min. RESULTS: A significant increase in food intake was observed following systemic and intracranial (10 nmol) application of morphine in all experiments. SR 141716 suppressed systemic and intra-PVN morphine induced feeding (experiments 2 and 4), but did not attenuate food intake induced by intra-nAcc application of morphine (experiment 3). CONCLUSIONS: Because SR 141716 had no effect on intra-nAcc morphine-stimulated feeding, it would appear that cannabinoid receptors do not modify opioid-mediated hedonic responses to food. Rather, we conclude that cannabinoid CB(1) receptor blockade may suppress opioid-induced feeding by stimulating the release of satiety-related peptides within the hypothalamus. Further, because SR 141716 did not block morphine induced locomotor activity, the observed effects on feeding do not appear to be due to a non-specific reduction in motivated behaviour.