Learning to See: Using Mixed OR Methods to Model Radiology Staff Workload and Support Decision Making in CT.

Demand for Computer Tomography (CT) is growing year on year and the population of Ireland is increasingly aging and ailing. Anecdotally, radiology staff reported increasing levels of workload associated with the patient profile. In this paper, we propose a framework combining discrete event simulation (DES) modeling and soft systems methodologies (SSM) for use in healthcare which captures the staff experience and metrics to evidence workload. The framework was applied in a single-scanner CT department, which completes circa 6000 examinations per year. The scanner case load consists of unscheduled work [inpatient (IP) and emergency department (ED)] and scheduled work [outpatient (OP) and general practitioner (GP)]. The three stage framework is supported by qualitative and quantitative methods and uses DES as a decision support tool. Firstly, workflow mapping and system dynamics are used to conceptualize the problem situation and instigate a preliminary data analysis. Secondly, SSM tools are used to identify components for a DES model and service improvement scenarios. Lastly, the DES model results are used to inform decision-making and identify a satisficing solution. Data from the DES model provided evidence of the differing workload (captured in staff time) for the IP and OP cohorts. For non-contrast examinations, inpatient workload is 2.5 times greater than outpatient. Average IP process delays of 11.9 min were demonstrated compared to less than 1 min for OP. The findings recommend that OP and IP diagnostic imaging be provided separately, for efficiency, workload management and infection control reasons.

Making the cut: Depression screening in urban general hospital clinics for culturally diverse Latino populations.

OBJECTIVES: We examined whether the cut-point 10 for the Patient Health Questionnaire-9 (PHQ9) depression screen used in primary care populations is equally valid for Mexicans (M), Ecuadorians (E), Puerto Ricans (PR) and non-Hispanic whites (W) from inner-city hospital-based primary care clinics; and whether stressful life events elevate scores and the probability of major depressive disorder (MDD). METHODS: Over 18-months, a sample of persons from hospital clinics with a positive initial PHQ2 and a subsequent PHQ9 were administered a stressful life event questionnaire and a Structured Clinical Interview to establish an MDD diagnosis, with oversampling of those between 8 and 12: (n=261: 75 E, 71 M, 51 PR, 64 W). For analysis, the sample was weighted using chart review (n=368) to represent a typical clinic population. Receiver Operating Characteristics analysis selected cut-points maximizing sensitivity (Sn) plus specificity (Sp). RESULTS: The optimal cut-point for all groups was 13 with the corresponding Sn and Sp estimates for E=(Sn 73%, Sp 71%), M=(76%, 81%), PR=(81%, 63%) and W=(80%, 74%). Stressful life events impacted screen scores and MDD diagnosis. CONCLUSIONS: Elevating the PHQ9 cut-point for inner-city Latinos as well as whites is suggested to avoid high false positive rates leading to improper treatment with clinical and economic consequences.

Possible Interplay Between Hospital and Community Transmission of a Novel Clostridium Difficile Sequence Type 295 Recognized by Next-Generation Sequencing.

OBJECTIVE To use next-generation sequencing (NGS) analysis to enhance epidemiological information to identify and resolve a Clostridium difficile outbreak and to evaluate its effectiveness beyond the capacity of current standard PCR ribotyping. METHODS NGS analysis was performed as part of prospective surveillance of all detected C. difficile isolates at a university hospital. An outbreak of a novel C. difficile sequence type (ST)-295 was identified in a hospital and a community hostel for homeless adults. Phylogenetic analysis was performed of all ST-295 and closest ST-2 isolates. Epidemiological details were obtained from hospital records and the public health review of the community hostel. RESULTS We identified 7 patients with C. difficile ST-295 infections between June 2013 and April 2015. Of these patients, 3 had nosocomial exposure to this infection and 3 had possible hostel exposure. Current Society for Healthcare Epidemiology of America (SHEA)- Infectious Diseases Society of America (IDSA) surveillance definitions (2010) were considered in light of our NGS findings. The initial transmission was not detectable using current criteria, because of 16 weeks between ST-295 exposure and symptoms. We included 3 patients with hostel exposure who met surveillance criteria of hospital-acquired infection due to their hospital admissions. CONCLUSION NGS analysis enhanced epidemiological information and helped identify and resolve an outbreak beyond the capacity of standard PCR ribotyping. In this cluster of cases, NGS was used to identify a hostel as the likely source of community-based C. difficile transmission. Infect Control Hosp Epidemiol 2016;37:680-684.

Use of a standardized patient paradigm to enhance proficiency in risk assessment for adolescent depression and suicide.

PURPOSE: Although routine adolescent depression and suicide risk assessment (ADSRA) is recommended, primary care physician (PCP) ADSRA training is needed for successful ADSRA implementation. This study examined the effect of an intervention using standardized patients (SPs) on PCP ADSRA confidence, knowledge, and practices. METHODS: The intervention consisted of a 60-minute seminar followed by a 60-minute SP session to practice ADSRA skills in simulated clinical situations. INTERVENTION: PCPs (n = 46) completed pre- and postintervention assessments. Untrained PCPs interested in the intervention (n = 58) also completed assessments. Assessments evaluated ADSRA self-reported confidence and practices and objectively assessed knowledge. The main outcomes were (1) changes in pre-/postintervention PCP ADSRA confidence and knowledge, and (2) ADSRA practices in untrained versus postintervention PCPs. RESULTS: Compared with untrained PCPs, PCPs 5-10 months postintervention were more likely to screen most adolescents for depression (40% vs. 22%, p = .05), to use a depression screening tool (50% vs. 19%, p = .001), to have diagnosed at least one adolescent with depression in the past 3 months (96% vs. 78%, p = .013), and to have screened depressed adolescents for suicide risk factors, including access to weapons (51% vs. 25%; p = .007) or an impulsive violence history (27% vs. 11%; p = .037). PCP confidence and knowledge about depression assessment and treatment also significantly improved postintervention. CONCLUSIONS: This study supports the use of an SP intervention to improve PCP ADSRA confidence, knowledge, and practices. Widespread implementation of similar educational efforts has the potential to dramatically improve adolescent morbidity and mortality.

Measuring emergency department nurses' attitudes towards deliberate self-harm using the Self-Harm Antipathy Scale.

The emergency department is an important gateway for the treatment of self-harm patients. Nurses' attitudes towards patients who self-harm can be negative and often nurses experience frustration, helplessness, ambivalence and antipathy. Patients are often dissatisfied with the care provided, and meeting with positive or negative attitudes greatly influences whether they seek additional help. A quantitative design was utilised to measure emergency department nurses' attitudes towards deliberate self-harm. The 'Self-Harm Antipathy Scale', a validated questionnaire, was administered to a random sample of nurses in four emergency departments in the Republic of Ireland. A total of 87 questionnaires were returned (87% response rate). Results reveal that nurses show slightly negative antipathy overall, indicating positive attitudes towards self-harming patients. Attitudes were significantly different in accordance with a nurse's age. Education and social judgment also contribute to the way nurses view, interact and make moral decisions regarding self-harm patients. Evidence indicates there is need to improve the training, supervision and support of nurses caring for patients who self-harm, and that practical strategies should be implemented to manage the alienation process and inform practice.

Colonization, bloodstream infection, and mortality caused by vancomycin-resistant enterococcus early after allogeneic hematopoietic stem cell transplant.

Bloodstream infection caused by vancomycin-resistant enterococcus (VRE) is associated with very high mortality among allogeneic hematopoietic stem cell transplant (alloHSCT) recipients. However, it remains unclear whether VRE bloodstream infection directly causes mortality in the early posttransplant period or is simply a marker of poor outcome. To determine the risk factors for VRE bloodstream infection and its effect on outcome, we followed 92 patients screened for stool colonization by VRE upon admission for alloHSCT. Patient records were reviewed to determine outcomes, including mortality and microbiologic failure. Colonization by VRE was extremely common, occurring in 40.2% of patients. VRE bloodstream infection developed in 34.2% of colonized patients by day +35, compared to 1.8% without VRE colonization (P < .01). VRE bloodstream infection was associated with a significant decrement in survival and frequent microbiologic failure, despite treatment with linezolid and/or daptomycin. Five (35.7%) of 14 patients with VRE bloodstream infection had attributable mortality or contributing mortality from the infection. Strain typing by pulsed-field gel electrophoresis identified 9 different VRE strains among the 37 colonized patients and 5 patients with different strains recovered from the stool and the blood. In conclusion, stool screening effectively identified patients at extremely high risk for VRE bloodstream infection. The high mortality of VRE in the early posttransplant period supports the use of empiric antibiotics with activity against VRE during periods of fever and neutropenia in colonized patients.