Electronic risk assessment for venous thromboembolism: investigating physicians' rationale for bypassing clinical decision support recommendations.

Objective: The underutilisation of venous thromboembolism (VTE) prophylaxis is still a problem in the UK despite the emergence of national guidelines and incentives to increase the number of patients undergoing VTE risk assessments. Our objective was to examine the reasons doctors gave for not prescribing enoxaparin when recommended by an electronic VTE risk assessment alert. Design: We used a qualitative research design to conduct a thematic analysis of free text entered into an electronic prescribing system. Setting: The study took place in a large University teaching hospital, which has a locally developed electronic prescribing system known as PICS (Prescribing, Information and Communication System). Participants: We extracted prescription data from all inpatient admissions over a 7-month period in 2012 using the audit database of PICS. Intervention: The completion of the VTE risk assessment form introduced into the hospital-wide electronic prescribing and health records system is mandatory. Where doctors do not prescribe VTE prophylaxis when recommended, they are asked to provide a reason for this decision. The free-text field was introduced in May 2012. Primary and Secondary Outcome Measures: Free-text reasons for not prescribing enoxaparin when recommended were thematically coded. Results: A total of 1136 free-text responses from 259 doctors were collected in the time period and 1206 separate reasons were analysed and coded. 389 reasons (32.3%) for not prescribing enoxaparin were coded as being due to 'clinical judgment'; in 288 (23.9%) of the responses, doctors were going to reassess the patient or prescribe enoxaparin; and in 245 responses (20.3%), the system was seen to have produced an inappropriate alert. Conclusions: In order to increase specificity of warnings and avoid users developing alert fatigue, it is essential that an evaluation of user responses and/or end user feedback as to the appropriateness and timing of alerts is obtained

Ex-vivo perfusion bioassay : an excellent technique to measure the bioactivity of inhalable insulin coated microcrystals

Purpose: To measure the bioactivity of inhalable insulin coated microcrystals using a perfusion bioassay that measures its vasodilatory effect on smooth muscle arterial tissue. Methods: The bioactivity of an insulin protein coated microcrystal (PCMC), a potential candidate for pulmonary drug delivery and commercial insulin was determined on a Danish Myo Tech P110 pressure myograph system. 12 week old Mesenteric resistance arteries from Male Wistar rats were isolated and immersed in a physiological salt solution (PSS) and attached to 2 opposing hollow glass micro-cannula (outer diameter 80 microns). The PSS was gradually warmed to 37°C (at a pressure less than 5mm Hg) for 1hr. Subsequently the pressure was increased up to 40mm Hg over a period 15 minutes and equilibrated for a further 15 minutes after gassing with 95%O2 / 5%CO2 to achieve a pH of 7.4 at 37°C. After normalisation by two washes of 123mM KCl and exposure to 1-10mM noradrenaline the arteries were exposed intraluminally to each insulin preparation by gradual infusion directly into the lumen via a fetal microcannulae inserted to the tip of the glass mounting cannula, at a constant pressure. Results: The preliminary results (full cummulative response curve yet to be determined) demonstrate insulin mediated relaxation to noradrenaline preconstriction. The level of constriction drops from 100% to 42% as the concentration of insulin increases from -11 to -9 Log M for the PCMC compared with a drop from 100 % to 65% for the commercial insulin preparation. However the more potent vasodilatory effect found for the insulin PCMC is more likely to be a result of variance introduced in each dilution step than a real increase in potency. Conclusion: The perfusion bioassay technique provides an excellent method of measuring insulin bioactivity and indicates the insulin loaded on the microcrystal support is fully active

Pharmacist-Physician Communications in a Highly Computerised Hospital:Sign-Off and Action of Electronic Review Messages

<div><p>Background</p><p>Some hospital Computerized Physician Order Entry (CPOE) systems support interprofessional communication. The aim of this study was to investigate the effectiveness of pharmacist-physician messages sent via a CPOE system.</p><p>Method</p><p>Data from the year 2012 were captured from a large university teaching hospital CPOE database on: 1) review messages assigned by pharmacists; 2) details of the prescription on which the messages were assigned; and 3) details of any changes made to the prescription following a review message being assigned. Data were coded for temporal, message and prescription factors. Messages were analysed to investigate: 1) whether they were signed-off; and 2) the time taken. Messages that requested a measurable action were further analysed to investigate: 1) whether they were actioned as requested; and 2) the time taken. We conducted a multivariable analysis using Generalised Estimating Equations (GEE) to account for the effects of multiple factors simultaneously, and to adjust for any potential correlation between outcomes for repeated review messages on the same prescription. All analyses were performed using SPSS 22 (IBM SPSS Inc., Chicago, IL, USA), with p<0.05 considered significant.</p><p>Results</p><p>Pharmacists assigned 36,245 review messages to prescriptions over the 12 months, 34,506 of which were coded for analysis after exclusions. Nearly half of messages (46.6%) were signed-off and 65.5% of these were signed-off in ≤ 48 hours. Of the 9,991 further analysed for action, 35.8% led to an action as requested by the pharmacist and just over half of these (57.0%) were actioned in ≤ 24 hours. Factors predictive of an action were the time since the prescription was generated (p<0.001), pharmacist grade (p<0.001), presence of a high-risk medicine (p<0.001), messages relating to reconciliation (p = 0.004), theme of communication (p<0.001), speciality, (p<0.001), category of medicine (p<0.001), and regularity of the prescription (p<0.001).</p><p>Conclusion</p><p>In this study we observed a lower rate of sign-off and action than we might have expected, suggesting uni-directional communication via the CPOE system may not be optimal. An established pharmacist-physician collaborative working relationship is likely to influence the prioritisation and response to messages, since a more desirable outcome was observed in settings and with grades of pharmacists where this was more likely. Designing systems that can facilitate collaborative communication may be more effective in practice.</p></div

Increased Trauma Activation Is Not Equally Beneficial For All Elderly Trauma Patients

Background Physiologic changes in the elderly lead to higher morbidity and mortality after injury. Increasing level of trauma activation has been proposed to improve geriatric outcomes; but, the increased cost to the patient and stress to the hospital system are significant downsides. The purpose of this study was to identify the age at which an increase in activation status is beneficial. Methods A retrospective review of trauma patients ≥ 70 years old from October 1, 2011, to October 1, 2016 was performed. On October 1, 2013, a policy change increased the activation criteria to the highest level for patients ≥ 70 years of age with a significant mechanism of injury. Patients who presented prior to (PRE) were compared to those after the change (POST). Data collected included age, injury severity score (ISS), length of stay (LOS), complications and mortality. Primary outcome was mortality and secondary outcome was LOS. Multivariable regressions controlled for age, ISS, injury mechanism, and number of complications. Results 4341 patients met inclusion criteria, 1919 in PRE and 2422 in POST. Mean age was 80.4 and 81 years in PRE and POST groups respectively (p=0.0155). Mean ISS values were 11.6 and 12.4 (p<0.0001) for the PRE and POST groups. POST had more level 1 activations (696 vs. 220, p<0.0001). After controlling for age, ISS, mechanism of injury, and number of complications, mortality was significantly reduced in the POST group ≥ age 77 years (OR 0.53, 95% CI: 0.3 - 0.87), (Figure 1). Hospital LOS was significantly reduced in the POST group ≥ age 78 (regression coefficient -0.55, 95% CI: -1.09, -0.01) (Figure 2). Conclusions This study suggests geriatric trauma patients ≥ 77 years benefit from the highest level of trauma activation with shorter LOS and lower mortality. A focused approach to increasing activation level for elderly patients may decrease patient cost. Level of Evidence Level III Type of Study Economic/Decisio

To Sleep, Perchance to Dream: Acute and Chronic Sleep Deprivation in Acute Care Surgeons

Background Acute and chronic sleep deprivation are significantly associated with depressive symptoms and felt to be contributors to the development of burnout. In-house call (IHC) inherently includes frequent periods of disrupted sleep and is common amongst acute care surgeons (ACS). The relationship between IHC and sleep deprivation (SD) amongst ACS has not been previously studied. The goal of this study was to determine prevalence and patterns of SD in ACS. Study Design: A prospective study of ACS with IHC responsibilities from two Level I trauma centers was performed. Participants wore a sleep tracking device continuously over a 3-month period. Data collected included age, gender, schedule of IHC, hours and pattern of each sleep stage (light, slow wave (SWS), and REM), and total hours of sleep. Sleep patterns were analyzed for each night excluding IHC and categorized as normal (N), acute sleep deprivation (ASD), or chronic sleep deprivation (CSD). Results 1421 nights were recorded amongst 17 ACS. (35.3% female; ages 37-65, mean 45.5 years). Excluding IHC, average amount of sleep was 6.54 hours with 64.8% of sleep patterns categorized as ASD or CSD. Average amount of sleep was significantly higher on post-call day 1 (6.96 hours, p=0.0016), but decreased significantly on post-call day 2 (6.33 hours, p=0.0006). Sleep patterns with ASD and CSD peaked on post-call day 2, and returned to baseline on post-call day 3 (p=0.046). Conclusion Sleep patterns consistent with ASD and CSD are common amongst ACS and worsen on post-call day 2. Baseline sleep patterns were not recovered until post-call day 3. Future study is needed to identify factors which impact physiologic recovery after IHC and further elucidate the relationship between SD and burnout

Evaluating the effectiveness of self-administration of medication (SAM) schemes in the hospital setting: a systematic review of the literature

BackgroundSelf-administration of medicines is believed to increase patients' understanding about their medication and to promote their independence and autonomy in the hospital setting. The effect of inpatient self-administration of medication (SAM) schemes on patients, staff and institutions is currently unclear.ObjectiveTo systematically review the literature relating to the effect of SAM schemes on the following outcomes: patient knowledge, patient compliance/medication errors, success in self-administration, patient satisfaction, staff satisfaction, staff workload, and costs.DesignKeyword and text word searches of online databases were performed between January and March 2013. Included articles described and evaluated inpatient SAM schemes. Case studies and anecdotal studies were excluded.Results43 papers were included for final analysis. Due to the heterogeneity of results and unclear findings it was not possible to perform a quantitative synthesis of results. Participation in SAM schemes often led to increased knowledge about drugs and drug regimens, but not side effects. However, the effect of SAM schemes on patient compliance/medication errors was inconclusive. Patients and staff were highly satisfied with their involvement in SAM schemes.ConclusionsSAM schemes appear to provide some benefits (e.g. increased patient knowledge), but their effect on other outcomes (e.g. compliance) is unclear. Few studies of high methodological quality using validated outcome measures exist. Inconsistencies in both measuring and reporting outcomes across studies make it challenging to compare results and draw substantive conclusions about the effectiveness of SAM schemes

Using serum CA125 to assess the activity of potential cytostatic agents in ovarian cancer

Objective: New strategies are required to rapidly identify novel cytostatic agents before embarking on large randomized trials. This study investigates whether a change in rate of rise (slope) of serum CA125 from before to after starting a novel agent could be used to identify cytostatic agents. Tamoxifen was used to validate this hypothesis. Methods: Asymptomatic patients with relapsed ovarian cancer who had responded to chemotherapy were enrolled and had CA125 measurements taken every 4 weeks, then more frequently when rising. Once levels reached 4 times the upper limit of normal or nadir, they started continuous tamoxifen 20 mg daily, as well as fortnightly CA125 measurements until symptomatic progression. Because of the potentially nonlinear relationship of CA125 over time, it was felt that to enable normal approximations to be utilized a natural logarithmic standard transformation [ln(CA125)] was the most suitable to improve linearity above the common logarithmic transformation to base 10. Results: From 235 recruited patients, 81 started tamoxifen and had at least 4 CA125 measurements taken before and 4 CA125 measurements taken after starting tamoxifen, respectively. The mean regression slopes from using at least 4 1n(CA125) measurements immediately before and after starting tamoxifen were 0I0149 and 0I0093 [ln(CA125)/d], respectively. This difference is statistically significant, P = 0I001. Therefore, in a future trial with a novel agent, at least as effective as tamoxifen, using this effect size, the number of evaluable patients needed, at significance level of 5% and power of 80%, is 56. Conclusions: Further validation of this methodology is required, but there is potential to use comparison of mean regression slopes of ln(CA125) as an interim analysis measure of efficacy for novel cytostatic agents in relapsed ovarian cancer.Peer reviewedFinal Accepted Versio

Investigating and learning lessons from early experiences of implementing ePrescribing systems into NHS hospitals:a questionnaire study

Background: ePrescribing systems have significant potential to improve the safety and efficiency of healthcare, but they need to be carefully selected and implemented to maximise benefits. Implementations in English hospitals are in the early stages and there is a lack of standards guiding the procurement, functional specifications, and expected benefits. We sought to provide an updated overview of the current picture in relation to implementation of ePrescribing systems, explore existing strategies, and identify early lessons learned.Methods: a descriptive questionnaire-based study, which included closed and free text questions and involved both quantitative and qualitative analysis of the data generated.Results: we obtained responses from 85 of 108 NHS staff (78.7% response rate). At least 6% (n = 10) of the 168 English NHS Trusts have already implemented ePrescribing systems, 2% (n = 4) have no plans of implementing, and 34% (n = 55) are planning to implement with intended rapid implementation timelines driven by high expectations surrounding improved safety and efficiency of care. The majority are unclear as to which system to choose, but integration with existing systems and sophisticated decision support functionality are important decisive factors. Participants highlighted the need for increased guidance in relation to implementation strategy, system choice and standards, as well as the need for top-level management support to adequately resource the project. Although some early benefits were reported by hospitals that had already implemented, the hoped for benefits relating to improved efficiency and cost-savings remain elusive due to a lack of system maturity.Conclusions: whilst few have begun implementation, there is considerable interest in ePrescribing systems with ambitious timelines amongst those hospitals that are planning implementations. In order to ensure maximum chances of realising benefits, there is a need for increased guidance in relation to implementation strategy, system choice and standards, as well as increased financial resources to fund local activitie