Nature and impact of interruptions on clinical workflow of medical residents in the inpatient setting.

BACKGROUND: Medical officers (trainees) in their first to third postgraduate years (PGY-1-3s) work in complex, busy environments, performing tasks that require concentration and application of learned skills. There are frequently competing demands, and being paged is among the most common. OBJECTIVE: We quantified and described the effect of interruptions that paging created on the clinical workflow of PGY-1-3s during ward duties. METHODS: This prospective study was conducted at 2 teaching hospitals in Sydney, Australia. Medical students were recruited as observers to log interruptions of PGY-1-3s' workflow arising from pages from other members of the hospital team. RESULTS: Forty-two pairs consisting of a PGY-1-3 trainee and an observer were recruited, with 24 proceeding to data collection. Nursing was the most frequent source of pages (47%); other medical staff accounted for 16% of pages, allied health for 12%, and others for 24% (with pharmacy the most common). Pages commonly involved direct patient care (46%), followed by medication issues (21%). Tasks interrupted by pages encompassed direct patient care (37%), indirect patient care (15%), and documentation (12%). Only 27% of pages were assessed as appropriate and urgent, while 58% were considered appropriate but not urgent, and 16% were not appropriate. Only 38% of pages were judged to be clinically more important than the task they interrupted. CONCLUSIONS: Pages frequently interrupted direct patient care activities for PGY-1-3 trainees, and a significant proportion of pages were identified as either not requiring immediate attention or not appropriate, resulting in potentially avoidable interruptions to clinical workflow. Alternate means of alerting trainees to nonurgent tasks may reduce interruptions and facilitate patient care.

Hypertrophic pulmonary osteoarthropathy demonstrated on SPECT/CT.

A 51-year-old man with a known history of hepatic cirrhosis and a right lung mass presented with hemoptysis and widespread bone pain. Sputum cytology demonstrated atypical cells. A CT scan of the chest demonstrated a 3-cm spiculating mass in the right lower lobe, in addition to nodules in both upper lobes and lymphadenopathy within the mediastinum and both hila. Skeletal scintigraphy was performed to assess for metastatic bone disease, and demonstrated increased tracer uptake along the cortex of the distal femurs bilaterally. There was also low-grade cortical uptake in the mid femur and tibia bilaterally on planar imaging. SPECT/CT was able to improve the specificity of the planar scintigraphic findings, by confirming tracer uptake was localized to the periosteum as expected for hypertrophic pulmonary osteoarthropathy, thereby excluding the presence of skeletal metastases.

Antibiotic prophylaxis in hip fracture surgery: a metaanalysis.

A metaanalysis was done to identify the most effective prophylactic antibiotic regimen in hip fracture surgery. Specific comparisons addressed were antibiotics at any dose versus placebo, multiple doses (>24 hours coverage) versus one dose of antibiotics, and multiple doses versus 24 hours antibiotic coverage. Outcomes measured included overall wound infections, deep wound infection, superficial wound infection, urinary tract infection, and mortality. A computer search of the Medline and EMBASE databases (English language literature from 1966 to 2000 and 1988 to 2000, respectively) retrieved 15 randomized controlled trials which addressed the specific aims. Most studies evaluated antibiotics from the cephalosporin group. Antibiotic prophylaxis significantly reduced overall wound infections when compared with placebo and was equally effective for deep and superficial infections. One dose of intravenous antibiotics seemed no different than multiple doses. Antibiotic use also was associated with a significant reduction in the incidence of urinary tract infection but had no significant effect on mortality.