Modeling patient-related workload in the emergency department using electronic health record data.

INTRODUCTION: Understanding and managing clinician workload is important for clinician (nurses, physicians and advanced practice providers) occupational health as well as patient safety. Efforts have been made to develop strategies for managing clinician workload by improving patient assignment. The goal of the current study is to use electronic health record (EHR) data to predict the amount of work that individual patients contribute to clinician workload (patient-related workload). METHODS: One month of EHR data was retrieved from an emergency department (ED). A list of workload indicators and five potential workload proxies were extracted from the data. Linear regression and four machine learning classification algorithms were utilized to model the relationship between the indicators and the proxies. RESULTS: Linear regression proved that the indicators explained a substantial amount of variance of the proxies (four out of five proxies were modeled with R2 > 0.80). Classification algorithms also showed success in classifying a patient as having high or low task demand based on data from early in the ED visit (e.g. 80 % accurate binary classification with data from the first hour). CONCLUSION: The main contribution of this study is demonstrating the potential of using EHR data to predict patient-related workload automatically in the ED. The predicted workload can potentially help in managing clinician workload by supporting decisions around the assignment of new patients to providers. Future work should focus on identifying the relationship between workload proxies and actual workload, as well as improving prediction performance of regression and multi-class classification.

Were domestic camelids present on the prehispanic South American agricultural frontier? An ancient DNA study.

The southern boundary of prehispanic farming in South America occurs in central Mendoza Province, Argentina at approximately 34 degrees south latitude. Archaeological evidence of farming includes the recovery of macrobotanical remains of cultigens and isotopic chemistry of human bone. Since the 1990s, archaeologists have also hypothesized that the llama (Lama glama), a domesticated South American camelid, was also herded near the southern boundary of prehispanic farming. The remains of a wild congeneric camelid, the guanaco (Lama guanicoe), however, are common in archaeological sites throughout Mendoza Province. It is difficult to distinguish bones of the domestic llama from wild guanaco in terms of osteological morphology, and therefore, claims that llama were in geographic areas where guanaco were also present based on osteometric analysis alone remain equivocal. A recent study, for example, claimed that twenty-five percent of the camelid remains from the high elevation Andes site of Laguna del Diamante S4 were identified based on osteometric evidence as domestic llama, but guanaco are also a likely candidate since the two species overlap in size. We test the hypothesis that domesticated camelids occurred in prehispanic, southern Mendoza through analysis of ancient DNA. We generated whole mitochondrial genome datasets from 41 samples from southern Mendoza late Holocene archaeological sites, located between 450 and 3400 meters above sea level (masl). All camelid samples from those sites were identified as guanaco; thus, we have no evidence to support the hypothesis that the domestic llama occurred in prehispanic southern Mendoza.

Design and Evaluation of an Integrated, Patient-Focused Electronic Health Record Display for Emergency Medicine.

BACKGROUND: Hospital emergency departments (EDs) are dynamic environments, involving coordination and shared decision making by staff who care for multiple patients simultaneously. While computerized information systems have been widely adopted in such clinical environments, serious issues have been raised related to their usability and effectiveness. In particular, there is a need to support clinicians to communicate and maintain awareness of a patient's health status, and progress through the ED plan of care. OBJECTIVE: This study used work-centered usability methods to evaluate an integrated patient-focused status display designed to support ED clinicians' communication and situation awareness regarding a patient's health status and progress through their ED plan of care. The display design was informed by previous studies we conducted examining the information and cognitive support requirements of ED providers and nurses. METHODS: ED nurse and provider participants were presented various scenarios requiring patient-prioritization and care-planning tasks to be performed using the prototype display. Participants rated the display in terms of its cognitive support, usability, and usefulness. Participants' performance on the various tasks, and their feedback on the display design and utility, was analyzed. RESULTS: Participants provided ratings for usability and usefulness for the display sections using a work-centered usability questionnaire-mean scores for nurses and providers were 7.56 and 6.6 (1 being lowest and 9 being highest), respectively. General usability scores, based on the System Usability Scale tool, were rated as acceptable or marginally acceptable. Similarly, participants also rated the display highly in terms of support for specific cognitive objectives. CONCLUSION: A novel patient-focused status display for emergency medicine was evaluated via a simulation-based study in terms of work-centered usability and usefulness. Participants' subjective ratings of usability, usefulness, and support for cognitive objectives were encouraging. These findings, including participants' qualitative feedback, provided insights for improving the design of the display.

Objective measures of workload in healthcare: a narrative review.

PURPOSE: Workload is a critical concept in the evaluation of performance and quality in healthcare systems, but its definition relies on the perspective (e.g. individual clinician-level vs unit-level workload) and type of available metrics (e.g. objective vs subjective measures). The purpose of this paper is to provide an overview of objective measures of workload associated with direct care delivery in tertiary healthcare settings, with a focus on measures that can be obtained from electronic records to inform operationalization of workload measurement. DESIGN/METHODOLOGY/APPROACH: Relevant papers published between January 2008 and July 2018 were identified through a search in Pubmed and Compendex databases using the Sample, Phenomenon of Interest, Design, Evaluation, Research Type framework. Identified measures were classified into four levels of workload: task, patient, clinician and unit. FINDINGS: Of 30 papers reviewed, 9 used task-level metrics, 14 used patient-level metrics, 7 used clinician-level metrics and 20 used unit-level metrics. Key objective measures of workload include: patient turnover (n=9), volume of patients (n=6), acuity (n=6), nurse-to-patient ratios (n=5) and direct care time (n=5). Several methods for operationalization of these metrics into measurement tools were identified. ORIGINALITY/VALUE: This review highlights the key objective workload measures available in electronic records that can be utilized to develop an operational approach for quantifying workload. Insights gained from this review can inform the design of processes to track workload and mitigate the effects of increased workload on patient outcomes and clinician performance.

Diagnosis of Hypofibrinogenemia After Dental Treatment Under General Anesthesia.

Congenital hypofibrinogenemia is a rare coagulation disorder characterized by a deficiency in fibrinogen protein, which is critical to the normal coagulation process. This hematological disorder can go undiagnosed until an event leads to prolonged bleeding. The purposes of this report were to describe an incidental diagnosis of congenital hypofibrinogenemia after a dental procedure, discuss the importance of recognizing coagulopathies on the delivery of dental care, examine the multi-disciplinary clinical management of prolonged bleeding after a dental procedure, and evaluate the challenges health care practitioners may encounter when obtaining a thorough medical history.

Synergistic antitumor activity of troxacitabine and camptothecin in selected human cancer cell lines.

Troxacitabine (L-OddC) is an L-configuration deoxycytidine analog currently in phase II trials for the treatment of cancer. The cytotoxicity of L-OddC in combination with other anticancer agents has not been studied systematically. In the present study, we assessed the cytotoxic effects produced by the combinations of L-OddC and several commonly used chemotherapy drugs in a panel of cultured human cancer cell lines. Growth inhibition resulting from simultaneous exposure to two-drug combinations was determined using the methylene blue staining method. Camptothecin (CPT) and analogs exhibited additives to synergistic interactions with L-OddC by isobologram analysis. These effects were cell type-specific, with the most pronounced synergism being observed in KB oropharyngeal carcinoma and CPT-resistant KB100 cell lines. In KB cells, the total cellular uptake and DNA incorporation of L-OddC were increased by the addition of CPT. One explanation that emerged from enzyme assays of deoxycytidine kinase (dCK) and deoxycytidine monophosphate kinase (dCMPK), key enzymes involved in L-OddC phosphorylation, was that CPT protected against L-OddC-induced reduction in dCK and dCMPK activity. The resulting increase in l-OddC metabolites and incorporation into DNA was associated with enhanced L-OddC cytotoxicity. These findings will be useful in designing future clinical trials of combination chemotherapy with l-OddC and CPT analogs with the potential for a broad use against both hematological and solid tumors.

Technology evaluation: Matuzumab, Merck KGaA.

Merck KGaA is developing matuzumab, a fully humanized epidermal growth factor receptor (EGFR)-specific monoclonal antibody, as a potential treatment for EGFR-bearing tumors. Matuzumab is currently undergoing phase II clinical trials for gastric, cervical, pancreatic and ovarian cancers.

Lapatinib ditosylate GlaxoSmithKline.

Lapatinib ditosylate, an ErbB-2 and EGFR dual tyrosine kinase inhibitor, is being developed by GlaxoSmithKline plc for the potential treatment of solid tumors.

Erlotinib OSI/Roche/Genentech.

Erlotinib (CP-358774, OSI-774, Tarceva), a quinazoline derivative, is an orally active epidermal growth factor receptor tyrosine kinase inhibitor under development jointly by Genentech, OSI (formerly Oncogene Science) and Roche, both as monotherapy and combination therapy for the potential treatment of solid tumors, including non-small-cell lung cancer (NSCLC) and pancreatic, breast, head and neck cancers [203487]. Development of the compound is most advanced for NSCLC and pancreatic cancer; in July 2001, phase III combination trials were initiated for NSCLC [416835]. In October 2001, phase III monotherapy trials in NSCLC and phase III combination trials in pancreatic cancer were also initiated [426704]. In Japan, the compound was in phase I studies in January 2002 [439189].

Therapy for stage IIIB and stage IV non-small cell lung cancer.

The treatment options for unresectable stage III NSCLC include definitive RT, chemotherapy, combined chemoradiotherapy, or supportive care. Compared with radiation alone or chemotherapy alone, the combination of chemotherapy and standard RT confers a modest survival benefit at the cost of increased toxicity for patients with an excellent performance status. For metastatic disease, combination chemotherapy--in particular, platinum-based regimens--improves symptom control and survival. Newer chemotherapeutic agents with higher response rates and favorable toxicity profiles are improving outcome even for the elderly and debilitated patients and those refractory to first-line chemotherapy. Evolving understanding of the molecular events in tumorigenesis is uncovering a host of promising targets for mechanism-based therapy. Many of these novel target modulators likely will require combination with conventional chemotherapy for optimal results.

Angiogenesis in non-small cell lung cancer. A new target for therapy.

Non-small cell lung cancer (NSCLC) is cured with surgery in a minority of affected persons. Chemotherapy and radiation can palliate and extend survival of patients with disease not amenable to surgery. Consequently, new treatment options are urgently needed. In the era of molecularly targeted therapeutics, the recent direction in cancer research has been to identify and modulate specific events in tumorigenesis. Angiogenesis, or new vessel formation, is one such event elucidated to be fundamental to the development, growth, and metastasis of cancers and is one of the characteristics that differentiates tumor from host. Thus, targeting of tumor neovasculature continues to generate tremendous enthusiasm and effort in drug development. Extensive research into the role of angiogenesis in NSCLC has produced a host of novel targets; their potential inhibitors, now numbering over 40, are in various phases of clinical testing around the world. The current lead compounds include inhibitors of matrix metalloproteinases, angiogenic growth factors and their receptor tyrosine kinases. Despite their impressive activity in animal models, definitive evidence of their antitumor activity in humans is yet to be established. We face several challenges as we look to advance the field of antiangiogenesis for the treatment of cancer, namely, the need for a better understanding of the optimal timing and dosing of antiangiogenic agents, the validation of imaging and quantification methods of tumor angiogenesis, and a new clinical trials design for a more expedient evaluation of novel cytostatic target modulators.