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BACKGROUND: It is vital for residents to have a longitudinal view of their educational progression, and it is crucial for the medical education team to have a clear way to track resident progress over time. Current tools for aggregating resident data are difficult to use and do not provide a comprehensive way to evaluate and display resident educational advancement. OBJECTIVE: This study aims to describe the creation and assessment of a system designed to improve the longitudinal presentation, quality, and synthesis of educational progress for trainees. We created a new system for residency progress management with 3 goals in mind, that are (1) a long-term and centralized location for residency education data, (2) a clear and intuitive interface that is easy to access for both the residents and faculty involved in medical education, and (3) automated data input, transformation, and analysis. We present evaluations regarding whether residents find the system useful, and whether faculty like the system and perceive that it helps them save time with administrative duties. METHODS: The system was created using a suite of Google Workspace tools including Forms, Sheets, Gmail, and a collection of Apps Scripts triggered at various times and events. To assess whether the system had an effect on the residents, we surveyed and asked them to self-report on how often they accessed the system and interviewed them as to whether they found it useful. To understand what the faculty thought of the system, we conducted a 14-person focus group and asked the faculty to self-report their time spent preparing for residency progress meetings before and after the system debut. RESULTS: The system went live in February 2022 as a quality improvement project, evolving through multiple iterations of feedback. The authors found that the system was accessed differently by different postgraduate years (PGY), with the most usage reported in the PGY1 class (weekly), and the least amount of usage in the PGY3 class (once or twice). However, all of the residents reported finding the system useful, specifically for aggregating all of their evaluations in the same place. Faculty members felt that the system enabled a more high-quality biannual clinical competency committee meeting and they reported a combined time savings of 8 hours in preparation for each clinical competency committee as a result of reviewing resident data through the system. CONCLUSIONS: Our study reports on the creation of an automated, instantaneous, and comprehensive resident progress management system. The system has been shown to be well-liked by both residents and faculty. Younger PGY classes reported more frequent system usage than older PGY classes. Faculty reported that it helped facilitate more meaningful discussion of training progression and reduced the administrative burden by 8 hours per biannual session.
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Docentes Médicos , Internado y Residencia , Humanos , Encuestas y Cuestionarios , Educación de Postgrado en Medicina , Factores de TiempoRESUMEN
BACKGROUND: Hydroxychloroquine has not been associated with improved survival among hospitalized COVID-19 patients in the majority of observational studies and similarly was not identified as an effective prophylaxis following exposure in a prospective randomized trial. We aimed to explore the role of hydroxychloroquine therapy in mildly symptomatic patients diagnosed in the outpatient setting. METHODS: We examined the association between outpatient hydroxychloroquine exposure and the subsequent progression of disease among mildly symptomatic non-hospitalized patients with documented SARS-CoV-2 infection. The primary outcome assessed was requirement of hospitalization. Data was obtained from a retrospective review of electronic health records within a New Jersey USA multi-hospital network. We compared outcomes in patients who received hydroxychloroquine with those who did not applying a multivariable logistic model with propensity matching. RESULTS: Among 1274 outpatients with documented SARS-CoV-2 infection 7.6% were prescribed hydroxychloroquine. In a 1067 patient propensity matched cohort, 21.6% with outpatient exposure to hydroxychloroquine were hospitalized, and 31.4% without exposure were hospitalized. In the primary multivariable logistic regression analysis with propensity matching there was an association between exposure to hydroxychloroquine and a decreased rate of hospitalization from COVID-19 (OR 0.53; 95% CI, 0.29, 0.95). Sensitivity analyses revealed similar associations. QTc prolongation events occurred in 2% of patients prescribed hydroxychloroquine with no reported arrhythmia events among those with data available. CONCLUSIONS: In this retrospective observational study of SARS-CoV-2 infected non-hospitalized patients hydroxychloroquine exposure was associated with a decreased rate of subsequent hospitalization. Additional exploration of hydroxychloroquine in this mildly symptomatic outpatient population is warranted.
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Tratamiento Farmacológico de COVID-19 , Hidroxicloroquina/administración & dosificación , Adulto , Anciano , COVID-19/virología , Femenino , Hospitalización , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , New Jersey , Pacientes Ambulatorios/estadística & datos numéricos , Estudios Retrospectivos , SARS-CoV-2/efectos de los fármacos , SARS-CoV-2/genética , SARS-CoV-2/fisiología , Índice de Severidad de la EnfermedadRESUMEN
The problem of clinical documentation burden is ever-growing. Electronic documentation tools such as "dotphrases" were invented to help with the documentation burden. Despite the ubiquity of these tools, they are understudied. We present work on the usage of dotphrases within the emergency department. We find that dotphrases are most often used by medical scribes, they significantly increase note length, and are completely unstandardized as to their naming conventions, content, and usage. We find that there is inconsistent usage across and within providers and that there is much duplication in the dotphrase content. We also show that dotphrases have no effect on the time to complete and cosign a note. Finally, we demonstrate that even when accounting for patient complexity upon presentation, note authorship, and note length - notes with higher dotphrase usage are billed at higher billing levels.
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Documentación , Registros Electrónicos de Salud , Eficiencia , Servicio de Urgencia en Hospital , HumanosRESUMEN
BACKGROUND: The COVID-19 pandemic has inundated emergency departments with patients exhibiting a wide array of symptomatology and clinical manifestations. We aim to evaluate the chief complaints of patients presenting to our ED with either suspected or confirmed COVID-19 to better understand the clinical presentation of this pandemic. METHODS: This study was a retrospective computational analysis that investigated the chief complaints of all confirmed and suspected COVID-19 cases presenting to our adult ED (patients aged 22 and older) using a variety of data mining methods. Our study employed descriptive statistics to analyze the set of complaints that are most common, hierarchical clustering analysis to provide a nuanced way of identifying complaints that co-occur, and hypothesis testing identify complaint differences among age differences. RESULTS: A quantitative analysis of 5015 ED visits of COVID-suspected patients (1483 confirmed COVID-positive patients) identified 209 unique chief complaints. Of the 209 chief complaints, fever and shortness of breath were the most prevalent initial presenting symptoms. In the subset of COVID-19 confirmed positive cases, we discovered seven distinct clusters of presenting complaints. Patients over 65â¯years of age were more likely to present with weakness and altered mental status. CONCLUSIONS: Our research highlights an important aspect of the evaluation and management of COVID-19 patients in the emergency department. Our study identified most common chief complaints, chief complaints differences across age groups, and 7 distinct groups of COVID-19 symptoms. This large-scale effort to classify the most commonly reported symptoms in ED patients provides public health officials and providers with data for identifying COVID-19 cases.
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COVID-19/epidemiología , Servicio de Urgencia en Hospital/estadística & datos numéricos , Trastornos Mentales/epidemiología , Pandemias , Comorbilidad , Humanos , Estudios Retrospectivos , SARS-CoV-2 , Estados Unidos/epidemiologíaRESUMEN
Hydroxychloroquine has been touted as a potential COVID-19 treatment. Tocilizumab, an inhibitor of IL-6, has also been proposed as a treatment of critically ill patients. In this retrospective observational cohort study drawn from electronic health records we sought to describe the association between mortality and hydroxychloroquine or tocilizumab therapy among hospitalized COVID-19 patients. Patients were hospitalized at a 13-hospital network spanning New Jersey USA between March 1, 2020 and April 22, 2020 with positive polymerase chain reaction results for SARS-CoV-2. Follow up was through May 5, 2020. Among 2512 hospitalized patients with COVID-19 there have been 547 deaths (22%), 1539 (61%) discharges and 426 (17%) remain hospitalized. 1914 (76%) received at least one dose of hydroxychloroquine and 1473 (59%) received hydroxychloroquine with azithromycin. After adjusting for imbalances via propensity modeling, compared to receiving neither drug, there were no significant differences in associated mortality for patients receiving any hydroxychloroquine during the hospitalization (HR, 0.99 [95% CI, 0.80-1.22]), hydroxychloroquine alone (HR, 1.02 [95% CI, 0.83-1.27]), or hydroxychloroquine with azithromycin (HR, 0.98 [95% CI, 0.75-1.28]). The 30-day unadjusted mortality for patients receiving hydroxychloroquine alone, azithromycin alone, the combination or neither drug was 25%, 20%, 18%, and 20%, respectively. Among 547 evaluable ICU patients, including 134 receiving tocilizumab in the ICU, an exploratory analysis found a trend towards an improved survival association with tocilizumab treatment (adjusted HR, 0.76 [95% CI, 0.57-1.00]), with 30 day unadjusted mortality with and without tocilizumab of 46% versus 56%. This observational cohort study suggests hydroxychloroquine, either alone or in combination with azithromycin, was not associated with a survival benefit among hospitalized COVID-19 patients. Tocilizumab demonstrated a trend association towards reduced mortality among ICU patients. Our findings are limited to hospitalized patients and must be interpreted with caution while awaiting results of randomized trials. Trial Registration: Clinicaltrials.gov Identifier: NCT04347993.
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Anticuerpos Monoclonales Humanizados/uso terapéutico , Antimaláricos/uso terapéutico , Betacoronavirus , Infecciones por Coronavirus/tratamiento farmacológico , Hidroxicloroquina/uso terapéutico , Neumonía Viral/tratamiento farmacológico , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Anticuerpos Monoclonales Humanizados/farmacología , Azitromicina/uso terapéutico , COVID-19 , Niño , Preescolar , Infecciones por Coronavirus/mortalidad , Infecciones por Coronavirus/virología , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Hospitalización , Humanos , Lactante , Recién Nacido , Unidades de Cuidados Intensivos , Interleucina-6/antagonistas & inhibidores , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/mortalidad , Neumonía Viral/virología , Estudios Retrospectivos , SARS-CoV-2 , Resultado del Tratamiento , Adulto Joven , Tratamiento Farmacológico de COVID-19RESUMEN
Objective: Unintentional medication discrepancies contribute to preventable adverse drug events in patients. Patient engagement in medication safety beyond verbal participation in medication reconciliation is limited. We conducted a pilot study to determine whether patients' use of an electronic home medication review tool could improve medication safety during hospitalization. Materials and Methods: Patients were randomized to use a tool before or after hospital admission medication reconciliation to review and modify their home medication list. We assessed the quantity, potential severity, and potential harm of patients' and clinicians' medication changes. We also surveyed clinicians to assess the tool's usefulness. Results: Of 76 patients approached, 65 (86%) participated. Forty-eight (74%) made changes to their home medication list [before: 29 (81%), after: 19 (66%), p = .170]. Before group participants identified 57 changes that clinicians subsequently missed on admission medication reconciliation. Thirty-nine (74%) had a significant or greater potential severity, and 19 (36%) had a greater than 50-50 chance of harm. After group patients identified 68 additional changes to their reconciled medication lists. Fifty-one (75%) had a significant or greater potential severity, and 33 (49%) had a greater than 50-50 chance of harm. Clinicians reported believing that the tool would save time, and patients would supply useful information. Discussion: The results demonstrate a high willingness of patients to engage in medication reconciliation, and show that patients were able to identify important medication discrepancies and often changes that clinicians missed. Conclusion: Engaging patients in admission medication reconciliation using an electronic home medication review tool may improve medication safety during hospitalization.
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Computadoras de Mano , Conciliación de Medicamentos/métodos , Participación del Paciente , Adulto , Servicio de Urgencia en Hospital , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Seguridad del Paciente , Atención Dirigida al Paciente , Proyectos Piloto , Factores SocioeconómicosRESUMEN
INTRODUCTION: Despite evidence to support efficacy of early goal-directed therapy for resuscitation of patients with severe sepsis and septic shock in the emergency department, implementation remains incomplete. To identify and address specific barriers at our institution and maximize benefits of a planned sepsis treatment initiative, a baseline assessment of knowledge, attitudes, and behaviors regarding detection and treatment of severe sepsis was performed. METHODS: An online survey was offered to nurses and physicians in the emergency department of a major urban academic medical center. The questionnaire was designed to assess (1) baseline knowledge and self-reported confidence in identification of systemic inflammatory response syndrome and sepsis; (2) current practices in treatment; (3) difficulties encountered in managing sepsis cases; (4) perceived barriers to implementation of a clinical pathway based on early quantitative resuscitation goals; and (5) to elicit suggestions for improvement of sepsis treatment within the department. RESULTS: Respondents (n = 101) identified barriers to a quantitative resuscitation protocol for sepsis. These barriers included the inability to perform central venous pressure/central venous oxygen saturation monitoring, limited physical space in the emergency department, and lack of sufficient nursing staff. Among nurses, the greatest perceived contributor to delays in treatment was a delay in diagnosis by physicians; among physicians, a delay in availability of ICU beds and nursing delays were the greatest barriers. Despite these issues, respondents indicated that a written protocol would be helpful to them. DISCUSSION: Knowledge gaps and procedural hurdles identified by the survey will inform both educational and process components of an initiative to improve sepsis care in the emergency department.
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Vías Clínicas , Servicio de Urgencia en Hospital , Conocimientos, Actitudes y Práctica en Salud , Mejoramiento de la Calidad , Sepsis , Centros Médicos Académicos , Diagnóstico Precoz , Encuestas de Atención de la Salud , Implementación de Plan de Salud , Humanos , Pautas de la Práctica en Enfermería , Pautas de la Práctica en Medicina , Sepsis/diagnóstico , Sepsis/enfermería , Sepsis/terapia , Choque Séptico/diagnóstico , Choque Séptico/terapia , Síndrome de Respuesta Inflamatoria Sistémica/diagnóstico , Síndrome de Respuesta Inflamatoria Sistémica/terapia , Estados UnidosAsunto(s)
Bacteriemia/diagnóstico , Bacteriemia/terapia , Enfermedades Transmitidas por los Alimentos/complicaciones , Hepatitis C/microbiología , Vibriosis/diagnóstico , Vibriosis/terapia , Vibrio vulnificus/aislamiento & purificación , Bacteriemia/microbiología , Bivalvos/microbiología , Resultado Fatal , Humanos , Masculino , Persona de Mediana Edad , New York , Práctica de Salud Pública , Mariscos/microbiología , Intoxicación por Mariscos , Vibriosis/microbiologíaRESUMEN
Cyanosis is a physical finding that can occur at any age but presents the greatest challenge when it occurs in the newborn. The cause is multiple, and it usually represents an ominous sign, especially when it occurs in association with neonatal sepsis, cyanotic congenital heart disease, and airway abnormalities. Cyanosis caused by abnormal forms of hemoglobin can also be life-threatening, and early recognition is mandatory to prevent unnecessary investigations and delay in management. Abnormal hemoglobin, such as hemoglobin M, is traditionally discovered by electrophoresis, so the newborn screen, which is mandatory in several states, is a useful tool for the diagnosis. Although acquired methemoglobinemia, caused by environmental oxidizing agents, is common, congenital deficiency of the innate reducing enzyme is so rare that only a few cases are documented in the medical literature around the world. We present a neonate with cyanosis as a result of congenital deficiency of the reduced nicotinamide adenine dinucleotide-cytochrome b5 reductase enzyme. This infant was found to be blue at a routine newborn follow-up visit. Sepsis, structural congenital heart disease, prenatal administration, and ingestion of oxidant dyes were excluded as a cause of the cyanosis by history and appropriate tests. Chocolate discoloration of arterial blood provided a clue to the diagnosis. A normal newborn screen and hemoglobin electrophoresis made the diagnosis of hemoglobin M unlikely as the cause of the methemoglobinemia (Hb A 59.4%, A2 1.8%, and F 38.8%). Red blood cell enzyme activity and DNA analysis revealed a homozygous form of the cytochrome b5 reductase enzyme deficiency. He responded very well to daily methylene blue and ascorbic acid administration, and he has normal growth and developmental parameters, although he shows an exaggerated increase in his methemoglobin level with minor oxidant stress such as diarrhea.