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.

Centralization and democratization: Managing crisis communication in health care delivery.

BACKGROUND: Communication is an essential organizational process for responding to adversity. Managers are often advised to communicate frequently and redundantly during crises. Nonetheless, systematic investigation of how information receivers perceive organizational communication amid crises has remained lacking. PURPOSE: The aim of this study was to characterize features of effective internal crisis communication by examining how information-sharing processes unfolded during the initial stage of the COVID-19 pandemic. METHODOLOGY: Between June and August 2020, we conducted 55 semistructured interviews with emergency department workers practicing in a variety of roles. We analyzed interview transcripts following constructivist constant comparative methods. RESULTS: Our findings revealed that at the onset of COVID-19 pandemic response, emergency department workers struggled with immense fear and anxiety amid high uncertainty and equivocality. Frequent and redundant communication, however, resulted in information delivery and uptake problems, worsening anxiety, and interpersonal tension. These problems were ameliorated by the emergence of contextual experts who centralized and democratized communication. Centralization standardized information received across roles, work schedules, and settings while decoupling internal communication from turbulence in the environment. Democratization made information accessible in a way that all could understand. It also ensured information senders' receptiveness to feedback from information receivers. Centralization and democratization together worked to reduce sensed uncertainty and equivocality, which reduced anxiety and interpersonal tension. CONCLUSION: Establishing frequent and redundant communication strategies does not necessarily address the anxiety and interpersonal tension produced by uncertainty and equivocality in crises. PRACTICE IMPLICATIONS: Centralization and democratization of crisis communication can reduce anxiety, improve coordination, and promote a safer workplace and patient care environment.

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.

Discharge Navigator: Implementation and Cross-Sectional Evaluation of a Digital Decision Tool for Social Resources upon Emergency Department Discharge.

INTRODUCTION: Many patients have unaddressed social needs that significantly impact their health, yet navigating the landscape of available resources and eligibility requirements is complex for both patients and clinicians. METHODS: Using an iterative design-thinking approach, our multidisciplinary team built, tested, and deployed a digital decision tool called "Discharge Navigator" (edrive.ucsf.edu/dcnav) that helps emergency clinicians identify targeted social resources for patients upon discharge from the acute care setting. The tool uses each patient's clinical and demographic information to tailor recommended community resources, providing the clinician with action items, pandemic restrictions, and patient handouts for relevant resources in five languages. We implemented two modules at our urban, academic, Level I trauma center. RESULTS: Over the 10-week period following product launch, between 4-81 on-shift emergency clinicians used our tool each week. Anonymously surveyed clinicians (n = 53) reported a significant increase in awareness of homelessness resources (33% pre to 70% post, P<0.0001) and substance use resources (17% to 65%, P<0.0001); confidence in accessing resources (22% to 74%, P<0.0001); knowledge of eligibility criteria (13% to 75%, P<0.0001); and ability to refer patients always or most of the time (11% to 43%, P<0.0001). The average likelihood to recommend the tool was 7.8 of 10. CONCLUSION: Our design process and low-cost tool may be replicated at other institutions to improve knowledge and referrals to local community resources.

Team and leadership factors and their relationship to burnout in emergency medicine during COVID-19: A 3-wave cross-sectional study.

Objective: We examined the relationship of team and leadership attributes with clinician feelings of burnout over time during the corona virus disease 2019 (COVID-19) pandemic. Methods: We surveyed emergency medicine personnel at 2 California hospitals at 3 time points: July 2020, December 2020, and November 2021. We assessed 3 team and leadership attributes using previously validated psychological scales (joint problem-solving, process clarity, and leader inclusiveness) and burnout using a validated scale. Using logistic regression models we determined the associations between team and leadership attributes and burnout, controlling for covariates. Results: We obtained responses from 328, 356, and 260 respondents in waves 1, 2, and 3, respectively (mean response rate = 49.52%). The median response for feelings of burnout increased over time (2.0, interquartile range [IQR] = 2.0-3.0 in wave 1 to 3.0, IQR = 2.0-3.0 in wave 3). At all time points, greater process clarity was associated with lower odds of feeling burnout (odds ratio [OR] [95% confidence interval (CI) = 0.36 [0.19, 0.66] in wave 1 to 0.24 [0.10, 0.61] in wave 3). In waves 2 and 3, greater joint problem-solving was associated with lower odds of feeling burnout (OR [95% CI] = 0.61 [0.42, 0.89], 0.54 [0.33, 0.88]). Leader inclusiveness was also associated with lower odds of feeling burnout (OR [95% CI] = 0.45 [0.27, 0.74] in wave 1 to 0.41 [0.24, 0.69] in wave 3). Conclusions: Process clarity, joint problem-solving, and leader inclusiveness are associated with less clinician burnout during the COVID-19 pandemic, pointing to potential benefits of focusing on team and leadership factors during crisis. Leader inclusiveness may wane over time, requiring effort to sustain.

How psychological safety and feeling heard relate to burnout and adaptation amid uncertainty.

BACKGROUND: Psychological safety-the belief that it is safe to speak up-is vital amid uncertainty, but its relationship to feeling heard is not well understood. PURPOSE: The aims of this study were (a) to measure feeling heard and (b) to assess how psychological safety and feeling heard relate to one another as well as to burnout, worsening burnout, and adaptation during uncertainty. METHODOLOGY: We conducted a cross-sectional survey of emergency department staff and clinicians (response rate = 52%; analytic N = 241) in July 2020. The survey measured psychological safety, feeling heard, overall burnout, worsening burnout, and perceived process adaptation during the COVID-19 crisis. We assessed descriptive statistics and construct measurement properties, and we assessed relationships among the variables using generalized structural equation modeling. RESULTS: Psychological safety and feeling heard demonstrated acceptable measurement properties and were correlated at r = .54. Levels of feeling heard were lower on average than psychological safety. Psychological safety and feeling heard were both statistically significantly associated with lower burnout and greater process adaptation. Only psychological safety exhibited a statistically significant relationship with less worsening burnout during crisis. We found evidence that feeling heard mediates psychological safety's relationship to burnout and process adaptation. CONCLUSION: Psychological safety is important but not sufficient for feeling heard. Feeling heard may help mitigate burnout and enable adaptation during uncertainty. PRACTICE IMPLICATIONS: For health care leaders, expanding beyond psychological safety to also establish a feeling of being heard may further reduce burnout and improve care processes.

Performance evaluation of virus concentration methods for implementing SARS-CoV-2 wastewater based epidemiology emphasizing quick data turnaround.

Wastewater based epidemiology (WBE) has drawn significant attention as an early warning tool to detect and predict the trajectory of COVID-19 cases in a community, in conjunction with public health data. This means of monitoring for outbreaks has been used at municipal wastewater treatment centers to analyze COVID-19 trends in entire communities, as well as by universities and other community living environments to monitor COVID-19 spread in buildings. Sample concentration is crucial, especially when viral abundance in raw wastewater is below the threshold of detection by RT-qPCR analysis. We evaluated the performance of a rapid ultrafiltration-based virus concentration method using InnovaPrep Concentrating Pipette (CP) Select and compared this to the established electronegative membrane filtration (EMF) method. We evaluated sensitivity of SARS-CoV-2 quantification, surrogate virus recovery rate, and sample processing time. Results suggest that the CP Select concentrator is more efficient at concentrating SARS-CoV-2 from wastewater compared to the EMF method. About 25% of samples that tested negative when concentrated with the EMF method produced a positive signal with the CP Select protocol. Increased recovery of the surrogate virus control using the CP Select confirms this observation. We optimized the CP Select protocol by adding AVL lysis buffer and sonication, to increase the recovery of virus. Sonication increased Bovine Coronavirus (BCoV) recovery by 19%, which seems to compensate for viral loss during centrifugation. Filtration time decreases by approximately 30% when using the CP Select protocol, making this an optimal choice for building surveillance applications where quick turnaround time is necessary.

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.

Masked and distanced: a qualitative study of how personal protective equipment and distancing affect teamwork in emergency care.

BACKGROUND: Newly intensified use of personal protective equipment (PPE) in emergency departments presents teamwork challenges affecting the quality and safety of care at the frontlines. OBJECTIVE: We conducted a qualitative study to categorize and describe barriers to teamwork posed by PPE and distancing in the emergency setting. METHODS: We conducted 55 semi-structured interviews between June 2020 and August 2020 with personnel from two emergency departments serving in a variety of roles. We then performed a thematic analysis to identify and construct patterns of teamwork challenges into themes. RESULTS: We discovered two types of challenges to teamwork: material barriers related to wearing masks, gowns and powered air-purifying respirators, and spatial barriers implemented to conserve PPE and limit coronavirus exposure. Both material and spatial barriers resulted in disrupted communication, roles and interpersonal relationships, but they did so in unique ways. Material barriers muffled information flow, impeded team member recognition and role/task division, and reduced belonging and cohesion while increasing interpersonal strain. Spatial barriers resulted in mediated communication and added physical and emotional distance between teammates and patients. CONCLUSION: Our findings identify specific aspects of how intensified PPE use disrupts teamwork and can inform efforts to ensure care quality and safety in emergency settings as PPE use continues during and, potentially beyond, the coronavirus disease-2019 pandemic.

Implementing building-level SARS-CoV-2 wastewater surveillance on a university campus.

The COVID-19 pandemic has been a source of ongoing challenges and presents an increased risk of illness in group environments, including jails, long-term care facilities, schools, and residential college campuses. Early reports that the SARS-CoV-2 virus was detectable in wastewater in advance of confirmed cases sparked widespread interest in wastewater-based epidemiology (WBE) as a tool for mitigation of COVID-19 outbreaks. One hypothesis was that wastewater surveillance might provide a cost-effective alternative to other more expensive approaches such as pooled and random testing of groups. In this paper, we report the outcomes of a wastewater surveillance pilot program at the University of North Carolina at Charlotte, a large urban university with a substantial population of students living in on-campus dormitories. Surveillance was conducted at the building level on a thrice-weekly schedule throughout the university's fall residential semester. In multiple cases, wastewater surveillance enabled the identification of asymptomatic COVID-19 cases that were not detected by other components of the campus monitoring program, which also included in-house contact tracing, symptomatic testing, scheduled testing of student athletes, and daily symptom reporting. In the context of all cluster events reported to the University community during the fall semester, wastewater-based testing events resulted in the identification of smaller clusters than were reported in other types of cluster events. Wastewater surveillance was able to detect single asymptomatic individuals in dorms with resident populations of 150-200. While the strategy described was developed for COVID-19, it is likely to be applicable to mitigation of future pandemics in universities and other group-living environments.

Streamlining Care in Crisis: Rapid Creation and Implementation of a Digital Support Tool for COVID-19.

The unprecedented COVID-19 pandemic has resulted in rapidly evolving best practices for transmission reduction, diagnosis, and treatment. A regular influx of new information has upended traditionally static hospital protocols, adding additional stress and potential for error to an already overextended system. To help equip frontline emergency clinicians with up-to-date protocols throughout the evolving COVID-19 crisis, our team set out to create a dynamic digital tool that centralized and standardized resources from a broad range of platforms across our hospital. Using a design thinking approach, we rapidly built, tested, and deployed a solution using simple, out-of-the-box web technology that enables clinicians to access the specific information they seek within moments. This platform has been rapidly adopted throughout the emergency department, with up to 70% of clinicians using the digital tool on any given shift and 78.6% of users reporting that they "agree" or "strongly agree" that the platform has affected their management of COVID-19 patients. The tool has also proven easily adaptable, with multiple protocols being updated nearly 20 times over two months without issue. This paper describes our development process, challenges, and results to enable other institutions to replicate this process to ensure consistent, high-quality care for patients as the COVID-19 pandemic continues its unpredictable course.