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Background Heart failure and sleep-disordered breathing have been increasingly recognized as co-occurring conditions. Their bidirectional relationship warrants investigation into whether heart failure therapy improves sleep and sleep-disordered breathing. We sought to explore the effect of treatment with sacubitril/valsartan on sleep-related endpoints from the AWAKE-HF study. Methods and Results AWAKE-HF was a randomized, double-blind study conducted in 23 centers in the United States. Study participants with heart failure with reduced rejection fraction and New York Heart Association class II or III symptoms were randomly assigned to receive treatment with either sacubitril/valsartan or enalapril. All endpoints were assessed at baseline and after 8 weeks of treatment. Portable sleep-monitoring equipment was used to measure the apnea-hypopnea index, including obstructive and central events. Total sleep time, wake after sleep onset and sleep efficiency were exploratory measures assessed using wrist actigraphy. The results were as follows 140 patients received treatment in the double-blind phase (sacubitril/valsartan, n = 70; enalapril, n = 70). At baseline, 39% and 40% of patients randomly assigned to receive sacubitril/valsartan or enalapril, respectively, presented with undiagnosed, untreated, moderate-to-severe sleep-disordered breathing (≥ 15 events/h), and nearly all had obstructive sleep apnea. After 8 weeks of treatment, the mean 4% apnea-hypopnea index changed minimally from 16.3/h to 15.2/h in the sacubitril/valsartan group and from 16.8/h to 17.6/h in the enalapril group. Mean total sleep time was long at baseline and decreased only slightly in both treatment groups at week 8 (–14 and –11 minutes for sacubitril/valsartan and enalapril, respectively), with small changes in wake after sleep onset and sleep efficiency in both groups. Conclusions In a cohort of patients with heart failure with reduced rejection fraction who met prescribing guidelines for sacubitril/valsartan, one-third had undiagnosed moderate-to-severe obstructive sleep apnea. The addition of sacubitril/valsartan therapy did not significantly improve sleep-disordered breathing or sleep duration or efficiency. Patients who meet indications for treatment with sacubitril/valsartan should be evaluated for sleep-disordered breathing.

OBJECTIVE Different health information technology (health IT) systems are intended to support medication ordering, reviewing, and administration. We sought to identify the types of medication errors associated with health IT use, whether they reached the patient, where in the medication process those errors occurred, and the specific usability issues contributing to those errors. METHODS Patient safety event reports from more than 595 healthcare facilities entered between January 2013 and September 2018 were analyzed. We computationally identified reports associated with health IT intended to support the medication process, including computerized provider order entry, electronic medication administration record, and barcode medication administration. From these, 2700 reports were manually reviewed to determine the type of medication error, medication process stage, and health IT usability issue. RESULTS Of the 2700 manually reviewed reports, 1508 (55.9%) described a medication error that was associated with health IT use and 750 (49.7%) reached the patient. Improper dose errors were frequent (1214 of 1508, 80.5%) with most errors during ordering (673 of 1508, 44.6%) and reviewing medications (639 of 1508, 42.4%). Most health IT-associated medication error reports described usability issues (n = 1468 of 1508, 97.3%) including data entry, workflow support, and alerting. Data entry usability issues impacted few medication process stages, whereas workflow support and alerting impacted several stages. CONCLUSIONS Health IT usability issues are a prevalent contributing factor to medication errors, many of which reach the patient. Data entry, workflow support, and alerting should be prioritized during usability and safety optimization efforts.

Introduction: Dog bites are a significant health concern in the pediatric population. Few studies published to date have stratified the injuries caused by dog bites based on surgical severity to elucidate the contributing risk factors. Methods: We used an electronic hospital database to identify all patients ≤17 years of age treated for dog bites from 2013–2018. Data related to patient demographics, injury type, intervention, dog breed, and payer source were collected. We extracted socioeconomic data from the American Community Survey. Data related to dog breed was obtained from public records on dog licenses. We calculated descriptive statistics as well as relative risk of dog bite by breed. Results: Of 1,252 injuries identified in 967 pediatric patients, 17.1% required consultation with a surgical specialist for repair. Bites affecting the head/neck region were most common (61.7%) and most likely to require operating room intervention (P = 0.002). The relative risk of a patient being bitten in a low-income area was 2.24, compared with 0.46 in a high-income area. Among cases where the breed of dog responsible for the bite was known, the dog breed most commonly associated with severe bites was the pit bull (relative risk vs German shepherd 8.53, relative risk vs unknown, 3.28). Conclusion: The majority of injuries did not require repair and were sufficiently handled by an emergency physician. Repair by a surgical specialist was required

Non-governmental organizations (NGOs) aim to alleviate unmet global disease burden and promote collaboration between visiting and host countries. Well-executed emergency response protocols are foundational to providing safe and quality care in an unpredictable global setting. Global Smile Foundation (GSF) instituted a protocol in 2012 based on over three decades of cleft care experience. Here, we update this protocol and provide information on how to address special circumstances such as humanitarian crises and disease outbreaks. The GSF response protocol was developed in conjunction with surgeons, anesthesiologists, nurses, and administrators to ensure all team members are adequately prepared to respond to emergency situations in global outreach. This protocol provides information on pre-departure preparation, onsite setup, operative precautions, and post-departure debriefings. Emphasis is placed on a standardized, reproducible workflow that accounts for necessary site-specific adjustments. Strategies include emergency simulations, site-specific safety checklists, standardized operating room protocols, and well-defined individual responsibilities. The authors also provide anticipatory guidance in addressing unexpected circumstances, such as disease outbreak and natural disaster, during global outreach. In conclusion, a proactive and systematic approach to emergency response and prevention is vital to minimizing morbidity and mortality during surgical outreach initiatives. The GSF protocol represents a reproducible approach that other organizations can adopt and adapt to their unique needs.

Introduction The Manufacturer and User Facility Device Experience (MAUDE) database houses medical device reports submitted to the U.S. Food and Drug Administration (FDA). In May 2020, the FDA released guidance about medical device reporting during a pandemic, anticipating delays in reporting and investigating events involving medical devices. Methods We aimed to understand how the COVID-19 pandemic impacted medical device reporting by analyzing reports in the MAUDE database that mention COVID-19. Results From the 816,470 reports submitted between January 1 and July 31, 2020, 3,500 (0.43%) included phrases related to COVID-19. Of these reports, 4.8% (167/3,500) described adverse events during COVID-19 patients’ treatment, and 90.3% (3,161 /3,500) described barriers manufacturers faced investigating malfunctioning devices during the pandemic. 4.9% (172/3,500) of reports were not related to COVID-19. Malfunctions were clinically significant in 85.8% (3,004/3,500) of reports. Discussion Reports indicate challenges some manufacturers had when investigating medical devices during the pandemic. The pandemic made investigating implants uniquely difficult, as restrictions to person-to-person contact limited the type of care patients could receive. Because full-scale investigations into malfunctioning devices may be difficult to perform during the pandemic, safety issues may go unaddressed and result in future harm to patients. Conclusion The COVID-19 pandemic and the myriad of healthcare, travel, and shipping challenges it created impacted how manufacturers reported and investigated medical devices. At the current time, it is unclear how manufacturers will address delayed clinical management of implant devices and other uninvestigated malfunctions after the pandemic and how this will impact patient safety.

The COVID-19 pandemic has rapidly accelerated the adoptionof on-demand telehealth as a way to keep patients and providers safe from viral transmission. However, theconstrained timelines and challenging conditions under which telehealth was implemented along with the factthat many patientsand providers are interacting in a new modality raisesconcerns about the potential for unintended patient safety risks that have yet to be fully understood. With the surge in telehealth patient volumeduringthe pandemic,on demand telehealth has served as a way to triageand refer patients who need additional in-person evaluation and treatment. One safety concern is whether patients who are referred are successfully following through on in-person care referrals as thefailure to seekin-person care may lead to increased risk of delayed or missed diagnosis. This study aimsto evaluate whether patientsare successfully fulfilling their in -person referralsfollowingareferralfromon-demandtelehealth through retrospective analysis of a subset of telehealth referral datafrom a large healthcare system. Of the 911 on-demand telehealth visitswith a referral to in-person care, only 689showed anin-person care encounter following the telehealthvisit and only 75-85% ofmore immediate urgency in-person referrals were fulfilled within the recommended time period of 24 hours. This preliminary data highlights theneed for amore comprehensiveanalysisof the telehealth referral processand the application of human factors methodsto understand and address barriers and risks associated with telehealth referrals and successful follow up.

A nonpunitive approach to safety event reporting and analysis is an important dimension of healthcare organization safety culture. A system-based safety event review process, one focused on understanding and improving the conditions in which individuals do their work, generally leads to more effective and sustainable safety solutions. On the contrary, the more typical person-based approach, that blames individuals for errors, often results in unsustainable and ineffective safety solutions, but these solutions can be faster and less resource intensive to implement. We sought to determine the frequency of system-based and person-based approaches to adverse event reviews through analysis of the recommendation text provided by a healthcare organization in response to an event report. Human factors and clinical safety science experts developed a taxonomy to describe the content of the recommendation text, reviewed 8,546 event report recommendations, and assigned one or more taxonomy category labels to each recommendation. The taxonomy categories aligned with a system-based approach, aligned with a person-based approach, did not provide an indicator of the approach, or indicated the review/analysis was pending. A total of 9,848 category labels were assigned to the 8,546 event report recommendations. The most frequently used category labels did not provide an indicator of the approach to event review (4,145 of 9,848 category labels, 42.1%), followed by a person-based approach (2,327, 23.6%), review/analysis pending (1,862 ,18.9%), and a system-based approach (1,514, 15.4%). Analyzing the data at the level of each recommendation, 23.2% (1,979 of 8,546) had at least one person-based and no system-based category, 13.3% (1,133) had at least one system-based and no person-based category, and 3% (254) had at least one person-based and one system-based category. There was variability in the event review approach based on the general event type assigned to the safety event (e.g., medication, transfusion, etc.) as well as harm severity. Results suggest improvements in applying system-based approaches are needed, especially for certain general event type categories. Recommendations for improving safety event reviews are provided.

Objective To derive 7 proposed core electronic health record (EHR) use metrics across 2 healthcare systems with different EHR vendor product installations and examine factors associated with EHR time. Materials and Methods A cross-sectional analysis of ambulatory physicians EHR use across the Yale-New Haven and MedStar Health systems was performed for August 2019 using 7 proposed core EHR use metrics normalized to 8 hours of patient scheduled time. Results Five out of 7 proposed metrics could be measured in a population of nonteaching, exclusively ambulatory physicians. Among 573 physicians (Yale-New Haven N = 290, MedStar N = 283) in the analysis, median EHR-Time8 was 5.23 hours. Gender, additional clinical hours scheduled, and certain medical specialties were associated with EHR-Time8 after adjusting for age and health system on multivariable analysis. For every 8 hours of scheduled patient time, the model predicted these differences in EHR time (P Conclusions For every 8 hours of scheduled patient time, ambulatory physicians spend more than 5 hours on the EHR. Physician gender, specialty, and number of clinical hours practicing are associated with differences in EHR time. While audit logs remain a powerful tool for understanding physician EHR use, additional transparency, granularity, and standardization of vendor-derived EHR use data definitions are still necessary to standardize EHR use measurement.

Background Migraine headache is a common, debilitating condition responsible for astronomical societal burden. The chronicity of migraine headaches necessitates the use of many healthcare services. Preventative treatment remains the desirable option for this patient population. Pharmacologic advances have led to the development of erenumab, a monoclonal antibody calcitonin gene-related peptide receptor antagonist that directly interferes with the known biochemical pathway of migraine initiation. Alternatively, surgical decompression of migraine trigger sites is a historically effective preventative option for certain patients experiencing migraine headaches. As new treatments emerge, the large economic burden of migraine headaches requires cost evaluation against already available preventative modalities. Methods Studies evaluating the cost-effectiveness of both erenumab and surgical trigger site deactivation were found using EMBASE and MedLine. Relevant economic data was extracted from this literature and the cost of treatment with erenumab was compared with surgical decompression. Results The market price of erenumab is $6900/yr. Speculative models predicted a direct annual healthcare cost ranging from $11,404 to $12,988 for patients experiencing episodic migraine. For chronic migraine patients, this range extended to $25,604. Annual indirect costs ranged from $7601 to $19,377. Prospective and model-based studies evaluating surgical trigger site deactivation reported an average 1 time surgical cost between $6956 and $10,303. In episodic migraine, subsequent annual healthcare costs were $900. Conclusions Erenumab has potential to be a revolutionary noninvasive preventative treatment for migraine headache. With that said, the cost-conscious option for patients receiving more than 1 year of treatment remains surgical trigger site deactivation.

Introduction On-demand telehealth can have a high rate of patients requesting visits and dropping off without being seen by a provider, especially during the COVID-19 pandemic. Methods On-demand telehealth requests made to a large healthcare system in the USA between 15 March 2020 and 31 May 2020 were included for analysis with a focus on patients who were defined as left without being seen (LWBS). As part of a pilot program a registered nurse attempted to call LWBS patients within 24 hours of their telehealth request and asked if they were ok, if they sought care for their original visit reason, what that care was, or if they still needed guidance. This information and patient demographics were analyzed. Results During the study period there were 21,610 completed on-demand telehealth visits and 1852 patients for whom there were LWBS attempted follow-ups. Most patients LWBS for a reason that originated from the patient and not associated with the provider or telehealth platform. The mean wait time for LWBS patients was 12.4 min compared to patients waiting 15.1 min before engaging with a provider to complete a visit. Of the 1852 total LWBS patients in the follow-up programme, 819 (44.2%) were successfully contacted with a follow-up phone call. Most of these patients (63.2%) already completed or planned to complete a telehealth visit, 13.6% indicated they no longer needed to see a provider, and 12.8% planned or already completed an in-person visit. Only 2.2% went to an emergency department. Discussion Results suggest patients can effectively self-manage their care needs.

Background Telemedicine is uniquely positioned to address challenges posed to emergency departments (EDs) by the COVID-19 pandemic. By reducing in-person contact, it should decrease provider risk of infection and preserve personal protective equipment (PPE). Objectives To describe and assess the early results of a novel telehealth workflow in which remote providers collaborate with in-person nursing to evaluate and discharge well-appearing, low-risk ED patients with suspected COVID-19 infection. Methods Retrospective chart review was completed three weeks after implementation. Metrics include the number of patients evaluated, number of patients discharged without in-person contact, telehealth wait time and duration, collection of testing, ED length of stay (ED-LOS), 72-hour return, number of in-person healthcare provider contacts, and associated PPE use. Results Among 302 patients evaluated by telehealth, 153 patients were evaluated and discharged by a telehealth provider with reductions in ED-LOS, PPE use, and close contact with healthcare personnel. These patients had a 62.5% shorter ED-LOS compared to other ESI Level 4 patients seen over the same time period. Telehealth use for these 153 patients saved 413 sets of PPE. We observed a 3.9% 72-hour revisit rate. One patient discharged after telehealth evaluation was hospitalized on a return visit 9 days later. Conclusion Telehealth can be safely and efficiently used to evaluate, treat, test, and discharge ED patients suspected to have COVID-19. This workflow reduces infection risks to healthcare providers, PPE use, and ED-LOS. Additionally, it allows quarantined but otherwise well clinicians to continue working., Article Summary: Why is this topic important? ● Telemedicine is uniquely positioned to address many of the challenges posed to emergency departments (EDs) by the COVID-19 pandemic. Using telehealth to evaluate and potentially discharge low-risk, well-appearing patients with suspected COVID-19 infection should decrease infection risk to providers, preserve personal protective equipment (PPE), and potentially mitigate surge. What does this study attempt to show? ● This study describes and assesses the preliminary results of a novel telehealth workflow in which remote providers collaborate with in-person nursing to evaluate and discharge well-appearing, low-risk ED patients with suspected COVID-19 infection. What are the key findings? ● One hundred fifty-three patients were evaluated and discharged by a telehealth provider, with reductions in length of stay, PPE use, and close contact with healthcare personnel. The practice appears safe, with a 3.9% 72-hour revisit rate. How is patient care impacted? ● Patients discharged by a telehealth provider had a 62.5% shorter length of stay compared to other ESI Level 4 patients seen over the same time period. Using telehealth to discharge these well-appearing patients can help unload a busy ED, mitigating surge. Reducing PPE usage and decreasing provider infection risk supports a sustained ED response to the continuing pandemic.

The incidence of anterior cruciate ligament (ACL) reconstruction is increasing in the United States, particularly in the older athlete. Patients who undergo ACL reconstruction are at higher risk for undergoing total knee arthroplasty (TKA) later in life. TKA in patients with prior ACL reconstruction has been associated with longer operative time due in-part to difficulty with exposure and retained hardware. Outcomes after TKA in patients with prior ACL reconstruction are not well defined, with some reports showing increased rate of complications and higher risk of reoperation compared with routine primary TKA, but these results are based on small and nonrandomized cohorts. Future research is needed to determine whether graft choice or fixation technique for ACL reconstruction influences outcomes after subsequent TKA. Furthermore, whether outcomes are affected by choice of TKA implant design for patients with prior ACL reconstruction warrants further study. This review analyzes the epidemiology, operative considerations, and outcomes of TKA following ACL reconstruction.

Periprosthetic joint infection (PJI) is a rare postoperative complication that is treated with antibiotic spacers. Some patients develop severe, treatment-resistant, chronic PJI despite multiple attempts at salvaging the joint. Permanent resection of the joint or amputation may be the only definitive treatment. The purpose of this study is to describe the outcomes, infection resolution rate, and complications of two-stage revision, utilizing extensive resection of the affected bone and application of antibiotic megaspacers as a modality for limb-salvage. A review of 12 patients, initially referred for amputation due to chronically failed PJI, was conducted. All patients underwent extensive resection of the bone and surgical implantation of a custom-made antibiotic megaspacer between December 2016 and June 2019. Thirteen megaspacers were placed in 13 infected joints in 12 patients with a history of chronic PJI. Six patients (50%) had a diagnosis of osteomyelitis. Eradication of the infection leading to limb-salvage was successful in nine patients. Visual Analog Scale pain scores improved by 3.5, or 50%, after two-stage revision with megaprosthesis reimplantation (p = .008), and six patients (54.5%) had improvement in ambulation. Complication rates, not including reinfection or recurrence, following megaspacer and megaprosthesis reimplantation were 58.3% and 27.3%, respectively. One patient underwent amputation due to a life-threatening infection while two other patients underwent amputation due to debilitating complications following limb-salvage surgery. Statement of Clinical Significance: In patients whose PJI becomes treatment-resistant after multiple failed attempts at traditional two-stage exchange, performing extensive boney resection with placement of an antibiotic-laden megaspacer can be an effective method of achieving limb-salvage.

Background Previous studies have found an association between functional status and outcomes following hip and knee arthroplasty. The purpose of this study was to evaluate the effect of dependent functional status on outcomes after total shoulder arthroplasty (TSA). Methods The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent primary TSA (anatomic or reverse) for glenohumeral osteoarthritis from January 1, 2011 to December 31, 2016. Patients whose preoperative functional status was dependent were compared with independent patients. Demographic data, length of hospital stay, and postoperative complications within 30 days were analyzed. Multivariable logistic regression was used to isolate the effect of functional status on postoperative complications and readmission. Results A total of 12,982 patients underwent primary TSA (anatomic or reverse) and 3.2% had a dependent functional status. Dependent patients had higher rate of comorbidities, higher mean American Society of Anesthesiologists class, longer hospital stays, and higher complication rates (including pneumonia, urinary tract infection, and blood transfusion). Logistic regression revealed that dependent functional status was an independent predictor for occurrence of any complication (odds ratio 2.0, P Conclusion Patients with dependent functional status preoperatively are at increased risk for short-term complications and readmission within 30 days following primary TSA. Level of evidence : Level III

AWAKE-HF evaluated the effect of the initiation of sacubitril/valsartan versus enalapril on activity and sleep using actigraphy in patients who have heart failure with reduced ejection fraction (HFrEF). In this randomized, double-blind study, patients with HFrEF (n = 140) were randomly assigned to sacubitril/valsartan or enalapril for 8 weeks, followed by an 8-week open-label phase with sacubitril/valsartan. Primary endpoint was change from baseline in mean activity counts during the most active 30 min/day at week 8. The key secondary endpoint was change in mean nightly activity counts/minute from baseline to week 8. Kansas City Cardiomyopathy Questionnaire-23 (KCCQ-23) was an exploratory endpoint. There were no detectable differences between groups in geometric mean ratio of activity counts during the most active 30 min/day at week 8 compared with baseline (0.9456 [sacubitril/valsartan:enalapril]; 95% confidence interval [CI] 0.8863–1.0088; P = 0.0895) or in mean change from baseline in activity during sleep (difference: 2.038 counts/min; 95% CI − 0.062 to 4.138; P = 0.0570). Change from baseline to week 8 in KCCQ-23 was 2.89 for sacubitril/valsartan and 4.19 for enalapril, both nonsignificant. In AWAKE-HF, no detectable differences in activity and sleep were observed when comparing sacubitril/valsartan with enalapril in patients with HFrEF using a wearable biosensor. ClinicalTrials.gov, NCT02970669.

Introduction: COVID-19 requires methods for screening patients that adhere to physical distancing and other Centers for Disease Control and Prevention guidelines. There is little data on the use of on-demand telehealth to meet this need. Methods: The functional performance of on-demand telehealth as a COVID-19 remote patient screening approach was conducted by analysing 9270 patient requests. Results: Most on-demand telehealth requests (5712 of 9270 total requests; 61.6%) had a visit reason that was likely COVID-19 related. Of these, 79.1% (4518 of 5712) resulted in a completed encounter and 20.9% (1194 of 5712) resulted in left without being seen. Of the 4518 completed encounters, 19.1% were referred to an urgent care centre, emergency department or COVID-19 testing centre. The average completed encounter wait time was 26.5 min and the mean visit length was 8.8 min. For patients that completed an encounter 42.8% (1935 of 4518) stated they would have sought in-person care and 9.1% stated they would have done nothing if on-demand telehealth was unavailable. Discussion: On-demand telehealth can serve as a low-barrier approach to screen patients for COVID-19. This approach can prevent patients from visiting healthcare facilities, which reduces physical contact and reduces healthcare worker use of personal protective equipment.

Communication for non-medication order (CNMO) is a type of free text communication order providers use for asynchronous communication about patient care. The objective of this study was to understand the extent to which non-medication orders are being used for medication-related communication. We analyzed a sample of 26 524 CNMOs placed in 6 hospitals. A total of 42% of non-medication orders contained medication information. There was large variation in the usage of CNMOs across hospitals, provider settings, and provider types. The use of CNMOs for communicating medication-related information may result in delayed or missed medications, receiving medications that should have been discontinued, or important clinical decision being made based on inaccurate information. Future studies should quantify the implications of these data entry patterns on actual medication error rates and resultant safety issues.

There is sparsity of data on outcomes following joint arthroplasty among polycythemia vera (PV) patients. The aim of this study is to evaluate postoperative outcomes following primary total knee (TKA) and hip (THA) arthroplasty among PV patients.A retrospective Medicare database review identified 6932 PV patients who underwent a primary total joint arthroplasty (4643 TKAs and 2289 THAs) from 2006 to 2013. A comparison of hospital length of stay, mortality, and the diagnosis of surgical site infections (SSIs), stroke, myocardial infarction, acute pulmonary embolism (PE), deep vein thrombosis (DVT), and other postoperative complications was made between PV patients undergoing TKA and THA and their respective matched control groups.PV was significantly associated with increased rates of acute PE (2.3% vs 1.6%; odds ratio [OR] 1.44, 95% confidence interval [CI] 1.17-1.75), DVT (4.2% vs 3.6%; OR 1.40, 95% CI 1.20-1.61, P.001), postoperative hematoma (0.6% vs 0.4%; OR 1.57, 95% CI 1.03-2.28), and SSI (4.5% vs 3.6%; OR 1.25, 95% CI 1.08-1.44, P = .002) following TKA. Among PV patients who underwent a primary THA, PV was significantly associated with increased rate of acute PE (1.9% vs 1.4%; OR 1.40, 95% CI 1.01-1.88, P = .035), DVT (3.5% vs 2.6%; OR 1.32, 95% CI 1.04-1.66, P = .035), postoperative hematoma (1.1% vs 0.6%; OR 1.86, 95% CI 1.22-2.80), and 1-year mortality (2.2% vs 1.6%; OR 1.43, 95% CI 1.06-1.89, P = .016).PV was significantly associated with increased risk for DVT, PE, postoperative hematoma, SSI (TKA only), and 1-year mortality (THA only) following primary total joint arthroplasty.

The human respiratory system mainly consists of four parts namely trachea, main bronchi, bronchioles and alveoli respectively. The alveoli in the lungs are responsible for the transfer of oxygen and carbon-dioxide through capillaries blood vessels leading to the pulmonary vein. A person cannot breathe properly during Chronic Obstructive Pulmonary Disease (COPD) due to abnormal transfer of oxygen and carbon-dioxide. Artificial ventilation is recommended for a person who suffers from COPD with no breathing or abnormal breathing, to manually preserve intact brain function. So, the blood oxygen level required for the person should be continuously monitored using pulse oximeter and controlled automatically using artificial ventilation. Hence, in this paper human respiratory system is modelled as analogies electrical model by using RLC parameters. The analogous electrical model parameters are represented as resistance, inheritance and compliance respectively. Using this analogous electrical model of human respiratory system, time domain and stability analysis are performed to identify COPD condition.

Purpose We conducted usability studies on commercially available molecular diagnostic (MDX) test reports to identify strengths and weaknesses in content and form that drive clinical decision making. Given routine genomic testing in cancer medicine, oncologists must interpret MDX reports as well as evidence concerning clinical utility of biomarkers accurately for treatment or trial selection. This work aims to evaluate effectiveness of MDX reports in facilitating cancer treatment planning. Methods Fourteen clinicians at an academic tertiary care medical facility, with a wide range of experience in oncology and in the use of molecular testing, participated in this study. Three commercially available, widely used, Clinical Laboratory Improvement Amendments (CLIA)–certified, College of American Pathologists (CAP)–accredited test reports (labeled Laboratories A, B, and C) were used. Eye tracking, surveys, and think-aloud protocols were used to collect usability data for these MDX reports focusing on ease of comprehension and actionability Results Clinicians found two primary areas in molecular diagnostic reports most useful for patient care: therapy options with benefit or lack of benefit to patients, including enrolling clinical trials; and pathogenic tumor molecular anomalies detected. Therapeutic implications and therapy classes such as US Food and Drug Administration–approved off-label, on-label, clinical trials were critical for decision making. However, all reports had usability and comprehension issues in these areas and could be improved. Conclusion Focused usability studies can help drive our understanding of the clinical workflow for use of molecular diagnostic tests in cancer care. This in turn can have major effects on quality of care, outcomes, costs, and patient satisfaction. This study demonstrates the use of specific usability techniques (eye tracking and think-aloud protocols) to help clinical laboratories improve MDX report design in a precision oncology treatment setting.

Computerized Provider Order Entry (CPOE) is a critical component of electronic health records (EHR). Although widely adopted, the usability of these systems is not well understood. A cross-sectional usability study was conducted at four healthcare systems using two commercially available EHRs. This research aims to predict the accuracy of an order placed in the EHR by emergency medicine physicians. Physician-EHR interactions were recorded during six simulated task scenarios in a test environment. The data from 222 interactions were used to predict the accuracy of the order placed. Multiple models were developed, and their performance was compared. The Random Forest model had the best performance with F1 score 0.82 and AUC of 0.89. These results demonstrate the utility of using keystroke, time and user demographics as variables in predicting accurate order placement. Applying such models to passively monitor EHR usage in real world clinical environments may help improve patient safety and care.

Introduction: The objective of this paper is to describe a manual annotation process to identify likely health information technology (IT) related patient safety event (PSE) reports and the descriptive analysis of the self-reported event type categories of the resulting likely health IT related events. Methods: 5287 PSE reports were manually coded as likely or unlikely related to health IT and the structured general and specific event type categories were analyzed. Results: Of the 2435 likely health IT related events, 1200 were categorized as medication error events, 709 described an error related to a procedure, treatment, or test, and the remaining events were distributed among 19 different general event types. Discussion: The variety of self-reported general and specific event categories indicates a potential need to provide additional support for individuals reporting events to capture contextual nuances and incorporating advanced techniques to assist researchers and safety officers in identifying health IT related events.

Opioid-related compartment syndrome (ORCS) is an understudied complication related to opioid overdose. We hypothesized that ORCS would be associated with worse clinical outcomes, including higher amputation rates, need for multiple surgical procedures, and rhabdomyolysis on admission, compared with nonopioid-related compartment syndrome (NORCS).We used Current Procedural Terminology codes for fasciotomy as a proxy marker for cases of compartment syndrome treated at 1 health system from January 1, 2016, to December 21, 2018. We excluded patients younger than 18 years, those treated for exertional compartment syndrome, and those who underwent elective fasciotomies. Seventy-four patients met our inclusion criteria. Data reviewed included patient characteristics, cause of compartment syndrome, time until evaluation for compartment syndrome, peak creatinine kinase levels, number of surgical procedures required, duration of hospital stay, and postoperative inpatient morbidity and death. Patients were categorized as having ORCS (n = 8) or NORCS (n = 66). Alpha = .05.All cases of ORCS occurred in men. Opioid use was the third most common cause of compartment syndrome. Two patients underwent amputation, both in the ORCS group (p 0.01). The median number of debridements was significantly higher for the ORCS group (median, 4; interquartile range [IQR]: 3-6) than for the NORCS group (median, 3; IQR 2-4) (p = 0.03). Duration of hospital stay was longer for the ORCS group (median, 27 days; IQR 16-38) compared with the NORCS group (median, 9 days; IQR: 5-13) (p 0.001). Mean (± standard deviation) peak creatinine kinase level was significantly higher in the ORCS group (224,000 ± 225,052 U/L) compared with the NORCS group (7550 ± 32,500) (p 0.001). The proportion of patients who underwent hemodialysis was higher in the ORCS group (88%) than in the NORCS group (35%) (p 0.001). All ORCS patients presented8 h after immobilization in a dependent position.Patients in the ORCS group had delayed presentations and significantly more morbidity compared with patients in the NORCS group.

Objective We analyzed the described resolutions of patient safety event reports related to health information technology to determine how healthcare systems responded to these events, recognizing that certain types of solutions such as training and education have a limited impact. Methods A large database of over 1.7 million patient safety event reports was filtered to include those identified by the reporter as being related to health information technology. The resolution text was manually reviewed and coded into one or more of four categories: No Resolution, Training/Education, Policy, Information Technology-oriented solution. Results Most events (64%) did not include a resolution. Of those that did, Training/Education was the most commonly reported single or component of a multi-pronged solution (55%), followed by Information Technology (45%). Only 59 events (6% of resolutions) described more than one method of resolution. Conclusion Health information technology-related patient safety event resolutions most often described a solution that suggested additional training or education for healthcare staff, despite the recognized limitations of training and education in resolving these events. Few events suggested multiple resolution methods. Ensuring health information technology-related events are resolved and incorporate effective solutions should be a continued focus area for healthcare systems.

Dog bites have been well described and characterized in the pediatric population. Comparatively, dog-bite injuries in adults and the settings in which surgeons become involved are less studied. An electronic hospital database identified all patients 18 years or older who were treated for dog bites from 2010 to 2014. Demographics, injury information, intervention type, and payer source were collected. Socioeconomic analysis was performed using Geographic Information Systems mapping. A total of 189 adults presented to the emergency department with dog-bite-related injuries. The most common injury location was the hand (n = 62, 32.8%), followed by the head and neck (n = 36, 19.1%). Of the 189 patients, 33 adults (17.5%) were forwarded to a surgical subspecialist for repair. A head and neck injury was significantly more likely to be repaired by a surgical specialist (P = 0.011). The most common breed of dog identified was pit bull (n = 29, 47.5%). The majority of pit bull attacks involved the extremities (65.5%) compared to other breeds of dogs. Pit bull victims were noted to have a lower average annual income compared to other breed victims ($64,708 versus $75,004; P = 0.16). Annual income between intervention group and no intervention group was not significantly different (P = 0.26). This study is the 1st to perform a socioeconomic analysis in the adult dog-bite population and encourages the use of a surgical specialist in the setting of a head and neck bite.

Objective The aim of this study was to investigate (1) why ordering clinicians use free-text orders to communicate medication information; (2) what risks physicians and nurses perceive when free-text orders are used for communicating medication information; and (3) how electronic health records (EHRs) could be improved to encourage the safe communication of medication information. Methods We performed semi-structured, scenario-based interviews with eight physicians and eight nurses. Interview responses were analyzed and grouped into common themes. Results Participants described eight reasons why clinicians use free-text medication orders, five risks relating to the use of free-text medication orders, and five recommendations for improving EHR medication-related communication. Poor usability, including reduced efficiency and limited functionality associated with structured order entry, was the primary reason clinicians used free-text orders to communicate medication information. Common risks to using free-text orders for medication communication included the increased likelihood of missing orders and the increased workload on nurses responsible for executing orders. Discussion Clinicians' use of free-text orders is primarily due to limitations in the current structured order entry design. To encourage the safe communication of medication information between clinicians, the EHR's structured order entry must be redesigned to support clinicians' cognitive and workflow needs that are currently being addressed via the use of free-text orders. Conclusion Clinicians' use of free-text orders as a workaround to insufficient structured order entry can create unintended patient safety risks. Thoughtful solutions designed to address these workarounds can improve the medication ordering process and the subsequent medication administration process.

BACKGROUND Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery. AIM To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients. METHODS In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05. RESULTS Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort. CONCLUSION The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.

Introduction Adjuvant therapy is recommended in duodenal adenocarcinoma (DA), but the role of neoadjuvant therapy remains undefined. We compared the effect of neoadjuvant therapy to adjuvant therapy on overall survival, 30-day, and 90-day mortality following the resection of DA. Methods A retrospective review of the National Cancer Database was performed on patients with DA who received either adjuvant or neoadjuvant therapy in addition to surgical resection. Propensity score matching was done for patient, socioeconomic, and tumor characteristics. Overall survival, 30-day, and 90-day mortality were compared. Results A total of 112 patients were identified; 55 received adjuvant therapy; 57 received neoadjuvant therapy. There was no difference in 30-day (0% vs. 1.75%; P = 1.00), 90-day mortality (1.82% vs. 7.02%; P = .36), nor overall survival (1 yr: 86% vs. 76; 3 yr: 49% vs. 46%; 5 yr: 42% vs. 39%; P = .28). Conclusions There was no difference in overall survival after propensity score matched analysis.

* Abbreviation: EHR — : electronic health record Nearly every office-based pediatrician now uses an electronic health record (EHR).1 There is now evidence that using EHRs can improve guideline adherence, reduce medication errors, and improve other measures of health care quality,2 but the rapid adoption of EHRs has also precipitated unintended and undesired consequences, including the poor usability of EHRs.3 Usability is the extent to which a technology can be used efficiently, effectively, and satisfactorily.4 Poor EHR usability results in clinician frustration, contributes to clinician burnout, and has direct patient safety consequences.5–7 To improve EHR usability, we need rigorous and robust measures of usability to identify specific problem areas, quantify the effect of improvement efforts, and facilitate product comparisons so that consumers can purchase products that meet their needs. In this issue of Pediatrics , Overhage and Johnson8 report on a large-scale analysis of Cerner Millennium EHR use in >20 million pediatric ambulatory encounters by almost 30 000 physicians. Their approach provides a broad assessment of the time spent on tasks in the EHR, and time on task is a usability measure commonly used to … Address correspondence to Raj Ratwani, PhD, National Center for Human Factors in Healthcare, Medstar Health Research Institute, MedStar Health, 3007 Tilden St NW, Suite 6N, Washington, DC 20008. E-mail: raj.m.ratwani{at}medstar.net

Fibrous dysplasia is a benign overgrowth of metaplastic fibrous material resulting in disorganized deposition of bony matrix. Surgical intervention is the primary treatment modality. Here the authors present the case of a 36-year-old male with extensive and severe fibrous dysplasia of the calvarium, orbit, sphenoid, and facial bones causing significant facial distortion and impingement of his optic nerve. Combined operative treatment with craniofacial plastic surgery and neurosurgery was performed. Repair consisted of extensive intra- and extracranial resection and contouring of involved bones followed by reconstruction of the superior orbital rims, forehead, orbital roof, and calvarium with custom polyetheretherketone (PEEK) implant. The authors discuss the advantages of using computer assisted design/modeling, intraoperative neuronavigation, and custom prosthetic cranioplasty for surgical treatment of extensive fibrous dysplasia; a review of the current surgical literature is provided.

Adolescents are disproportionately affected by sexually transmitted infections (STIs). Failure to diagnose and treat STIs in a timely manner may result in serious sequelae. Adolescents frequently access the emergency department (ED) for care. Although ED-based STI screening is acceptable to both patients and clinicians, understanding how best to implement STI screening processes into the ED clinical workflow without compromising patient safety or efficiency is critical. The objective of this study was to conduct direct observations documenting current workflow processes and tasks during patient visits at six Pediatric Emergency Care Applied Research Network (PECARN) EDs for site-specific integration of STI electronically-enhanced screening processes. Workflow observations were captured via TaskTracker, a time and motion electronic data collection application that allows researchers to categorize general work processes and record multitasking by providing a timestamp of when tasks began and ended. Workflow was captured during 118 patient visits across six PECARN EDs. The average time to initial assessment by the most senior provider was 76 min (range 59– 106 min, SD = 43 min). Care teams were consistent across sites, and included attending physicians, advanced practice providers, nurses, registration clerks, technicians, and students. A timeline belt comparison was performed. Across most sites, the most promising implementation of a STI screening tool was in the patient examination room following the initial patient assessment by the nurse.

OBJECTIVE Paradoxically, overweight and obesity are associated with lower odds of complications and death after hip fracture surgery. Our objective was to determine whether this "obesity paradox" extends to patients with "superobesity." In this study, we compared rates of complications and death among superobese patients with those of patients in other body mass index (BMI) categories. METHODS Using the National Surgical Quality Improvement Program database, we identified >100,000 hip fracture surgeries performed from 2012 to 2018. Patients were categorized as underweight (BMI

SUMMARY: Patients with low-energy hip fractures do not follow the obesity paradox as previously reported. In datasets where injury mechanism is not available, the use of age >50 years (as opposed to commonly used >65 years) as a surrogate for a low-energy hip fracture patients may be a more robust inclusion criterion. PURPOSE: In elderly patients with a hip fracture, limited data suggests that obese patients counterintuitively have improved survival compared to normal-weight patients. This "obesity paradox" may be the byproduct of selection bias. We hypothesized that the obesity paradox would not apply to elderly hip fracture patients. METHODS: The National Surgical Quality Improvement Project dataset identified 71,685 hip fracture patients ≥50 years-of-age with complete body mass index (BMI) data that underwent surgery. Patients were stratified into under and over 75-year-old cohorts (n=18,956 and 52,729, respectively). Within each age group, patients were stratified by BMI class and compared with respect to preoperative characteristics and 30-day mortality. Significant univariate characteristics (p

Heart failure (HF) is the leading cause of hospital readmission for patients over 65 years old in the United States. HF is a unique clinical condition requiring frequent monitoring of objective patient variables that cannot be accomplished by office visits alone. With the advent of smartphones, Bluetooth, and Wi-Fi technologies, an opportunity arose for the digital management of HF patients. This paper reviews the current digital technologies available in HF management and future directions that have the potential to change clinical practice. Implantable, wireless pulmonary artery hemodynamic monitoring systems, such as CardioMEMS, have shown strong evidence in reducing HF hospitalization. Wearable activity trackers can also be used to track functional status and rhythm abnormalities in HF; however, evidence that these devices improve clinical outcomes in HF is lacking. There is currently promise in non-invasive measurements of pulmonary congestion and cardiovascular hemodynamics using Remote Dieletric Sensing Technologies (ReDS), seismocardiography, and ballistocardiography, but these technologies are not routinely used in clinical practice. Future applications of digital technologies will likely incorporate personalized medicine to improve clinical care. Digital management of HF has emerged as a promising avenue for prevention of HF hospitalization. Although some technologies have shown to improve clinical outcomes, further studies are needed on currently existing technologies to assess their viability as tools in preventing rehospitalization. It is important for the clinician to understand the limitations of digital technologies, as well as their potential to worsen healthcare disparities.

Surgery for adult spinal deformity (ASD) is increasingly common. Although outcomes of ASD surgery have been studied extensively, to our knowledge, no data exist regarding factors predicting nonroutine discharge in this population. Nonroutine discharge is defined as discharge to a health care facility after surgery rather than to home.To determine which patient and surgical factors predict nonroutine discharge after ASD surgery.This is a retrospective study.We conducted a retrospective single-center study of 303 patients who underwent arthrodesis of five or more spinal levels to treat ASD between 2009 and 2014.Patients were stratified into two groups according to discharge disposition: home or nonroutine.Objective preoperative characteristics, intraoperative course, and postoperative recovery were analyzed to identify pre- and perioperative factors associated with nonroutine discharge. Univariate analysis was performed first. All factors with P values.2 on univariate analysis were included in a logistic regression model. Additionally, to understand the relationship between subjective patient-reported outcome measures and nonroutine discharge, we compared the two groups with respect to mean Oswestry Disability Index and Scoliosis Research Society-22r domains using Student t-tests.On univariate analysis, objective measures that differed significantly (P.05) between the two cohorts were age (≥65 years), osteoporosis, Charlson Comorbidity Index score of ≥2, prolonged hospital stay (8 days), and blood transfusion. Given the above logistic regression inclusion criteria, we controlled for the performance, and type, of osteotomy (P = .055). On multivariate analysis, older age, osteoporosis, prolonged hospital stay, blood transfusion, and 3-column osteotomy were independently associated with nonroutine discharge. Subjective patient-reported outcome measures, including Oswestry Disability Index and Scoliosis Research Society-22r physical function and pain domain scores, were significantly worse in the nonroutine discharge cohort (P.05).To our knowledge, this is the first study to evaluate pre- and perioperative factors associated with nonroutine discharge after ASD surgery. Elderly patients who undergo complex surgery and receive blood transfusions are at particularly high risk of nonroutine discharge. Surgeons should consider these factors during surgical planning and preoperative patient counseling.

Retrospective study.To analyze predictors of major blood loss (MBL) during multilevel arthrodesis for adult spinal deformity (ASD).ASD surgery is associated with substantial blood loss.We identified 237 patients with ASD who underwent spinal arthrodesis of five or more levels by one surgeon and who had complete data on blood loss. MBL was defined as normalized blood loss above the 75th percentile (ie,49%). Patients with MBL were compared with those without MBL with respect to baseline characteristics, preoperative laboratory values, and surgical factors. Alpha level = 0.05.A total of 176 patients (74%) had MBL. On univariate analysis, the MBL and non-MBL groups differed with respect to diagnosis of osteoporosis (p = .002), curve type (p = .012), number of levels fused (p.001), and presence/type of osteotomy (p.001). The groups were similar in age (p = .605) and proportion of patients undergoing revision surgery (p = .410). Multivariate analysis identified the following predictors of MBL: three-column osteotomy (odds ratio [OR] = 4.1, 95% confidence interval [CI] = 1.7, 9.7), arthrodesis of 11 or more levels (OR = 3.2, 95% CI = 1.4, 7.6), malalignment in both coronal and sagittal planes (OR = 3.2, 95% CI = 1.4, 7.3), and osteoporosis (OR = 2.4, 95% CI = 1.1, 5.4).Patients with ASD undergoing spinal arthrodesis of five or more levels are at risk for MBL. Three-column osteotomy, arthrodesis of ≥11 levels, malalignment in both coronal and sagittal planes, and osteoporosis appear to be risk factors for MBL.Level III.

The coronavirus disease 2019 (COVID-19) pandemic has prompted rapid restructuring of the health-care system in an effort to stop the spread of the virus and to treat patients who are acutely ill with COVID-19, while continuing to provide outpatient care for the remainder of patients. To help control spread of this pandemic, many centers, including total joint arthroplasty clinics, have boosted telemedicine capability to care for patients who would typically be seen in person in outpatient settings. We review key components relevant to the establishment and effective use of telemedicine, focused on patient education, practice logistics, technological considerations, and sensitive patient health information–associated compliance factors, which are necessary to provide care remotely for total joint arthroplasty patients.

Despite considerable evidence that psychosocial interventions can effectively relieve distress in patients with cancer, many individuals who could benefit from these interventions do not receive them. A proposed solution to this problem is the establishment of programs in oncology settings that routinely screen for distress and refer patients for appropriate psychosocial care. This commentary addresses a review by Ehlers et al. that describes policies and procedures related to distress screening, summarizes prior research on this topic, and identifies key areas for future research. Among their major conclusions is the need for research to fill the gap in knowledge about how best to implement new distress screening programs as well as optimize the use and efficiency of existing programs. This commentary focuses on how the types of study methods, designs, and outcomes that are commonplace in implementation science to facilitate the integration of research into practice can be applied to distress screening programs. Priorities identified include designing and conducting pragmatic clinical trials, evaluating multilevel interventions, and using hybrid designs to simultaneously evaluate clinical effectiveness and barriers and facilitators of implementation. Use of these approaches holds considerable potential for developing an evidence base that can promote more widespread adoption of effective distress screening programs and inform further development of standards and policies related to the psychosocial care of patients with cancer.

Rationale and Objectives The objective of this study was to experimentally test the effect of interruptions on image interpretation by comparing reading time and response accuracy of interrupted case reads to uninterrupted case reads in resident and attending radiologists. Materials and Methods Institutional review board approval was obtained before participant recruitment from an urban academic health-care system during January 2016–March 2016. Eleven resident and 12 attending radiologists examined 30 chest radiographs, rating their confidence regarding the presence or the absence of a pneumothorax. Ten cases were normal (ie, no pneumothorax present), 10 cases had an unsubtle pneumothorax (ie, readily perceivable by a nonexpert), and 10 cases had a subtle pneumothorax. During three reads of each case type, the participants were interrupted with 30 seconds of a secondary task. The total reading time and the accuracy of interrupted and uninterrupted cases were compared. A mixed-factors analysis of variance was run on reading time and accuracy with experience (resident vs attending) as a between-subjects factor and case type (normal, unsubtle, or subtle) and interruption (interruption vs no interruption) as within-subjects factors. Results Interrupted tasks had significantly longer reading times than uninterrupted cases (P = .032). During subtle cases, interruptions reduced accuracy (P = .034), but during normal cases, interruptions increased accuracy (P = .038). Conclusions Interruptions increased reading times and increased the tendency for a radiologist to conclude that a case is normal for both resident and attending radiologists, demonstrating that interruptions reduce efficiency and introduce patient safety concerns during reads of abnormal cases.

Background Interruptions can adversely impact human performance, particularly in fast-paced and high-risk environments such as the emergency department (ED). Understanding physician behaviors before, during, and after interruptions is important to the design and promotion of safe and effective workflow solutions. However, traditional human factors-based interruption models do not accurately reflect the complexities of real-world environments like the ED and may not capture multiple interruptions and multitasking. Methods We present a more comprehensive framework for understanding interruptions that is composed of three phases, each with multiple levels: interruption start transition, interruption engagement, and interruption end transition. This three-phase framework is not constrained to discrete task transitions, providing a robust method to categorize multitasking behaviors around interruptions. We apply this framework in categorizing 457 interruption episodes. Results A total of 457 interruption episodes were captured during 36 hours of observation. The interrupted task was immediately suspended 348 (76.1%) times. Participants engaged in new self-initiated tasks during the interrupting task 164 (35.9%) times and did not directly resume the interrupted task in 284 (62.1%) interruption episodes. Conclusion Using this framework provides a more detailed description of physician behaviors in complex environments. Understanding the different types of interruption and resumption patterns, which may have a different impact on performance, can support the design of interruption mitigation strategies.

Emergency Department (ED) congestion is a significant problem affecting clinical outcomes, patient satisfaction and hospital costs. Identifying and resolving bottlenecks in the flow of patients from the ED to eventual admission or discharge has the potential to reduce wait times, improve care for individual patients, and increase the volume of patients treated at the hospital over time. Our objective was to review methods commonly used to measure, analyze, and visualize patient flow, characterize drawbacks to these methods, and identify areas in which analysis and visualization can be improved to make bottlenecks easier to identify and resolve. Sixty-five articles obtained from PubMed and Google Scholar searches were reviewed to identify: (1) variables used to measure ED throughput; (2) downstream effects of ED congestion; (3) factors contributing to ED congestion; (4) techniques used to predict or respond to ED congestion; and (5) tools used to visualize data on ED throughput. Hospital resource availability, patient demographics, and environmental factors have all been used to predict contributors to ED congestion. Unfortunately, the hospital practices most critical to ED congestion are unlikely to change as they involve increasing the number of beds and providers or modifying protocols with EMS, insurance, and other care facilities. Therefore, interventions addressing optimization of ED resource allocation and visualization of ED data are the best avenue to yield more efficient ED operation.

Cutaneous chrysosporium infection is extremely rare and underdiagnosed. We present an immunocompromised patient who presented with recurrent cutaneous abscesses. Histopathology of the abscess showed thick-walled conidia and septate fungal hyphae within the subcutis and fungal culture grew Chrysosporium species.

Study objective The purpose of this study is to examine whether emergency physicians use strategies to manage interruptions during clinical work. Interruption management strategies include immediately engaging the interruption by discontinuing the current task and starting the interruption, continuing the current task while engaging the interruption, rejecting the interruption, or delaying the interruption. Methods An observational time and motion study was conducted in 3 different urban, academic emergency departments with 18 attending emergency physicians. Each physician was observed for 2 hours, and the number of interruptions, source of interruptions, type of task being interrupted, and use of interruption management strategies were documented. Results Participants were interrupted on average of 12.5 times per hour. The majority of interruptions were in person from other staff, including nurses, residents, and other attending physicians. When participants were interrupted, they were often working on their computer. Participants almost always immediately engaged the interruption task (75.4% of the time), followed by multitasking, in which the primary task was continued while the interrupting task was performed (22.2%). Physicians rejected or delayed interruptions less than 2% of the time. Conclusion Our results suggest there is an opportunity to introduce emergency physicians to the use of interruption management strategies as a method of handling the frequent interruptions they are exposed to. Use of these strategies when high-risk primary tasks are performed may reduce the disruptiveness of some interruptions and improve patient safety.

This study uses Department of Health and Human Services data to analyze surveillance of electronic health records for patient safety issues to identify those with a potential for patient harm, and the frequency of these issues.

STUDY DESIGN Retrospective database review OBJECTIVE.: The aim of this study was to analyze the implications of solid organ transplant (SOT) on postoperative outcomes following elective one or two-level anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Although SOTs have been associated with increased morbidity, postoperative outcomes in SOT recipients undergoing cervical spinal surgery are not well studied. METHODS A retrospective database review of Medicare patients younger than 85 years who underwent an elective one to two-level ACDF from 2006-2013 was conducted. Following our exclusion criteria, patients were then divided into the following groups: those with a prior history of kidney, liver, heart or lung transplant (SOT group) and non-SOT patients. Both groups were compared for hospital length of stay, 90-day major medical complications, 90-day hospital readmission, 1-year surgical site infection (SSI), 1-year revision ACDF, and 1-year mortality. RESULTS A total of 992 (0.5%) SOT recipients (1,144 organs) were identified out of 199,288 ACDF patients. SOT recipients had a significantly longer length of stay (2.32 vs. 5.22 days, p