2011 October 28

Characteristics of CPOE systems and obstacles to implementation that physicians believe will affect adoption.

Oct 282011

Characteristics of CPOE systems and obstacles to implementation that physicians believe will affect adoption.

South Med J. 2011 Jun;104(6):418-21

Authors: Singh D, Spiers S, Beasley BW

Abstract
BACKGROUND: Computerized Physician Order Entry (CPOE) has the potential to decrease medical errors and improve quality. Our health system plans to implement CPOE in response to the ARRA HITECH Act.
OBJECTIVES: To determine (A) physicians' projections of the most important characteristics of a CPOE system that will affect their willingness to adopt CPOE, and (B) the obstacles they foresee in adopting CPOE.
METHODS: All members of our health system's physician quality organization were invited to participate in a confidential survey.
RESULTS: Two hundred twenty-four of 549 (41%) recipients responded to the survey. Respondents ranked "disruption in my work routine" (72%) and "improve efficiency in placing orders" (63%) as the two most important characteristics that would affect their utilization of CPOE. They believed CPOE would enable orders to be placed more efficiently (3.3, sd = 1.2), carried out rapidly (3.4, sd = 0.9), and have fewer errors (3.7, sd = 0.9). The most commonly cited obstacles to CPOE implementation were: Efficiency-Inefficiency (23%), Hardware Availability (12.7%), Computer Restrictions (10.8%), Training (8.8%), Simplicity - Ease of Use (8.5%), and Physician Buy-in (8.1%).
CONCLUSIONS: The majority of physicians believed CPOE would lead to a reduction of medical errors and more efficient patient care. However, physicians are highly concerned with how CPOE will affect their own work efficiency.

PMID: 21886031 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Underestimation of urinary albumin to creatinine ratio in morbidly obese subjects due to high urinary creatinine excretion.

Clin Nutr Start a Discussion »

Oct 282011

Underestimation of urinary albumin to creatinine ratio in morbidly obese subjects due to high urinary creatinine excretion.

Clin Nutr. 2011 Oct 24;

Authors: Guidone C, Gniuli D, Castagneto-Gissey L, Leccesi L, Arrighi E, Iaconelli A, Mingrone G

Abstract
BACKGROUD&AIMS: Albuminuria, a chronic kidney and/or cardiovascular disease biomarker, is currently measured as albumin-to-creatinine ratio (ACR). We hypothesize that in severely obese individuals ACR might be abnormally low in spite of relatively high levels of urinary albumin due to increased creatininuria. METHODS: One-hundred-eighty-four subjects were divided into tertiles based on their BMI. Fat-free mass (FFM) and fat-mass were assessed by DEXA; 24-h creatinine and albumin excretion, ACR, lipid profile and blood pressure were measured. RESULTS: Twenty-four-hour creatinine highly correlated (R = 0.75) with FFM. Since both creatininuria and albuminuria increased with the BMI, being the increase in creatininuria preponderant in subjects with BMI>35, their ratio (AC-ratio) did not change significantly from that of subjects in the lower BMI tertile. ACR only correlated with the systolic blood pressure, while both albuminuria and cretininuria correlated (P = 0.01) with the absolute 10-year CHD risk. In subjects with BMI>35, 100 mg of albumin excreted with urine increased the CHD risk of 2%. CONCLUSIONS: Albumin-to-creatinine ratio is underestimated in severely obese individuals as a consequence of the large creatininuria, which is proportional to the increased FFM. Therefore, at least in this population 24-h albuminuria should be more reliable than ACR.

PMID: 22030400 [PubMed - as supplied by publisher]

Link to Article at PubMed

Involving Clinical Librarians at the Point of Care: Results of a Controlled Intervention.

Acad Med Start a Discussion »

Oct 282011

Involving Clinical Librarians at the Point of Care: Results of a Controlled Intervention.

Acad Med. 2011 Oct 25;

Authors: Aitken EM, Powelson SE, Reaume RD, Ghali WA

Abstract
PURPOSE: To measure the effect of including a clinical librarian in the health care team on medical residents and clinical clerks. METHOD: In 2009, medical residents and clinical clerks were preassigned to one of two patient care teams (intervention and control). Each team had a month-long rotation on the general medicine teaching unit. The clinical librarian joined the intervention team for morning intake, clinical rounding, or an afternoon patient list review, providing immediate literature searches, formal group instruction, informal bedside teaching, and/or individual mentoring for use of preappraised resources and evidence-based medicine search techniques. Both intervention and control teams completed pre and post surveys comparing their confidence levels and awareness of resources as well as their self-reported use of evidence for making patient care decisions. The nonintervention team was surveyed as the control group. RESULTS: The clinical librarian intervention had a significant positive effect on medical trainees' self-reported ability to independently locate and evaluate evidence resources to support patient care decisions. Notably, 30 of 34 (88%) reported having changed a treatment plan based on skills taught by the clinical librarian, and 27 of 34 (79%) changed a treatment plan based on the librarian's mediated search support. CONCLUSIONS: Clinical librarians on the care team led to positive effects on self-reported provider attitudes, provider information retrieval tendencies, and, notably, clinical decision making. Future research should evaluate economic effects of widespread implementation of on-site clinical librarians.

PMID: 22030761 [PubMed - as supplied by publisher]

Link to Article at PubMed

Can Eliminating Risk Stratification Improve Medical Residents’ Adherence to Venous Thromboembolism Prophylaxis?

Acad Med Start a Discussion »

Oct 282011

Can Eliminating Risk Stratification Improve Medical Residents' Adherence to Venous Thromboembolism Prophylaxis?

Acad Med. 2011 Oct 25;

Authors: Polich AL, Etherton GM, Knezevich JT, Rousek JB, Masek CM, Hallbeck MS

Abstract
PURPOSE: Hospital-acquired venous thromboembolism (VTE) is a common and preventable adverse event that most patients are at risk of developing during their hospital stay. VTE prophylactic anticoagulation (chemoprophylaxis) is the preferred pharmacological assignment for reducing risk of VTE, but it is underused in current practices involving risk stratification (RS) for VTE prevention. The purpose of this study was to determine whether a protocol that eliminates the RS step (non-RS protocol) is more likely to lead residents to evidence-based VTE assignment than the currently used RS protocol. The non-RS protocol follows a methodology that reduces complexity by assuming that the risk of VTE is present and uses contraindications to determine appropriate VTE assignment. METHOD: In 2009, 41 medicine residents at the Nebraska Western Iowa Veterans Affairs clinic participated in an online comparison of two different protocols (RS and non-RS) for assigning chemoprophylaxis for VTE. Six validated, hypothetical patient scenarios were used to compare appropriate (evidence-based) VTE assignments for VTE and completion times for each protocol. RESULTS: Statistical analyses found that the non-RS protocol produced significantly faster (P < .001) scenario completion times and significantly more (P < .001) appropriate VTE assignments than the RS protocol for four of the six patient scenarios. CONCLUSIONS: This study used a new, streamlined protocol (non-RS), which improved VTE assignment and the use of chemoprophylaxis and simplified the process when compared with the use of a traditional RS protocol.

PMID: 22030760 [PubMed - as supplied by publisher]

Link to Article at PubMed

Why do patients agree to a “Do not resuscitate” or “Full code” order? Perspectives of medical inpatients.

J Gen Intern Med Start a Discussion »

Oct 282011

Why do patients agree to a "Do not resuscitate" or "Full code" order? Perspectives of medical inpatients.

J Gen Intern Med. 2011 Jun;26(6):582-7

Authors: Downar J, Luk T, Sibbald RW, Santini T, Mikhael J, Berman H, Hawryluck L

Abstract
BACKGROUND: The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status.
METHODS: We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach.
RESULTS: We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia.
CONCLUSION: Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

PMID: 21222172 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

The role of nurse practitioners in hospital settings: implications for interprofessional practice.

J Interprof Care Start a Discussion »

Oct 282011

The role of nurse practitioners in hospital settings: implications for interprofessional practice.

J Interprof Care. 2011 Jul;25(4):245-51

Authors: Van Soeren M, Hurlock-Chorostecki C, Reeves S

Abstract
Expansion of the nurse practitioner (NP) role worldwide indicates a need to understand how the role functions in interprofessional healthcare teams. Through the adoption of a mixed methods approach that gathered on-site tracking and observation, self-recorded logs of consultations and focus group interviews of team members and NPs, we describe the extent of role activity and the nature of interprofessional practices of 46 NPs and their team members in nine hospital sites across the province of Ontario, Canada. Findings outline the nature of the NP role activities, which largely focused on providing clinical care, with the support of their team, to a range of patients across the study settings. We discuss how 'embedding' the NP in this way appears to contribute to utilization of expertise of all professions as well as enabling team members to promote evidence-based practices. We argue that the use of NPs augments interprofessional role utilization through their desire to consult with a range of professionals and the capacity to perform holistic care for patients that is not limited to traditional nursing boundaries.

PMID: 21182436 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

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