Medication decision-making for patients with renal insufficiency in inpatient and outpatient care at a US Veterans Affairs Medical Centre: a qualitative, cognitive task analysis.

BackgroundMany studies identify factors that contribute to renal prescribing errors, but few examine how healthcare professionals (HCPs) detect and recover from an error or potential patient safety concern. Knowledge of this information could inform advanced error detection systems and decision support tools that help prevent prescribing errors.ObjectiveTo examine the cognitive strategies that HCPs used to recognise and manage medication-related problems for patients with renal insufficiency.DesignHCPs submitted documentation about medication-related incidents. We then conducted cognitive task analysis interviews. Qualitative data were analysed inductively.SettingInpatient and outpatient facilities at a major US Veterans Affairs Medical Centre.ParticipantsPhysicians, nurses and pharmacists who took action to prevent or resolve a renal-drug problem in patients with renal insufficiency.OutcomesEmergent themes from interviews, as related to recognition of renal-drug problems and decision-making processes.ResultsWe interviewed 20 HCPs. Results yielded a descriptive model of the decision-making process, comprised of three main stages: detect, gather information and act. These stages often followed a cyclical path due largely to the gradual decline of patients' renal function. Most HCPs relied on being vigilant to detect patients' renal-drug problems rather than relying on systems to detect unanticipated cues. At each stage, HCPs relied on different cognitive cues depending on medication type: for renally eliminated medications, HCPs focused on gathering renal dosing guidelines, while for nephrotoxic medications, HCPs investigated the need for particular medication therapy, and if warranted, safer alternatives.ConclusionsOur model is useful for trainees so they can gain familiarity with managing renal-drug problems. Based on findings, improvements are warranted for three aspects of healthcare systems: (1) supporting the cyclical nature of renal-drug problem management via longitudinal tracking mechanisms, (2) providing tools to alleviate HCPs' heavy reliance on vigilance and (3) supporting HCPs' different decision-making needs for renally eliminated versus nephrotoxic medications

Computerised Clinical Reminders Use in an Integrated Healthcare System

Objective: To examine levels of routine computerised clinical reminder use in a nationwide sample of primary care physicians and to identify factors influencing reminder use. Design: Cross-sectional using a self-administered questionnaire. Setting: The United States Veterans Health Administration. Methods: Survey responses from 461 VHA primary care physicians sampled from across the Veterans Health Administration were sampled and analysed. We asked physicians how many computerised clinical reminders they use per patient per visit and when they typically use computerised clinical reminders in their clinics. Measured physician characteristics included age, gender, year of medical degree, number of days in clinic per week, and attitudes towards computerised clinical reminders (measured on Likert-like scales). We used multivariable linear regression to determine factors associated with greater use of computerised clinical reminders per patient per visit. Results: Average computerised clinical reminder use per patient visit was 4.2 (SD = 2.5). Eightysix percent of physicians resolve reminders during the visit. In a multivariable regression model, a higher score on the team factors scale is associated with use of more reminders (increase of 0.24 reminders for each unit increase on the team factors scale, or one extra reminder for each four unit increase in the team factor scale). Working more days in clinic is associated with use of more reminders per patient visit (increase of 0.13 reminders for each extra half-day of clinic per week, or about one additional reminder for physicians working ten half-days per week versus physicians working two half-days per week). Academic facility affiliation is associated with one less reminder used per patient visit as compared with no affiliation. Conclusions: Most United States Veterans Health Administration primary care physicians use computerised clinical reminders, typically during the patient visit. Strategies to increase reminder use should focus on improving physicians’ understanding of their role in completing reminder-related tasks and improving usability for users such as physicians who work in clinic less frequently

Rapid Bacterial and Fungal Successional Dynamics in First Year After Chaparral Wildfire

The rise in wildfire frequency and severity across the globe has increased interest in secondary succession. However, despite the role of soil microbial communities in controlling biogeochemical cycling and their role in the regeneration of post-fire vegetation, the lack of measurements immediately post-fire and at high temporal resolution has limited understanding of microbial secondary succession. To fill this knowledge gap, we sampled soils at 17, 25, 34, 67, 95, 131, 187, 286, and 376 days after a southern California wildfire in fire-adapted chaparral shrublands. We assessed bacterial and fungal biomass with qPCR of 16S and 18S and richness and composition with Illumina MiSeq sequencing of 16S and ITS2 amplicons. Fire severely reduced bacterial biomass by 47%, bacterial richness by 46%, fungal biomass by 86%, and fungal richness by 68%. The burned bacterial and fungal communities experienced rapid succession, with 5-6 compositional turnover periods. Analogous to plants, turnover was driven by fire-loving pyrophilous microbes, many of which have been previously found in forests worldwide and changed markedly in abundance over time. Fungal secondary succession was initiated by the Basidiomycete yeast Geminibasidium, which traded off against the filamentous Ascomycetes Pyronema, Aspergillus, and Penicillium. For bacteria, the Proteobacteria Massilia dominated all year, but the Firmicute Bacillus and Proteobacteria Noviherbaspirillum increased in abundance over time. Our high-resolution temporal sampling allowed us to capture post-fire microbial secondary successional dynamics and suggest that putative tradeoffs in thermotolerance, colonization, and competition among dominant pyrophilous microbes control microbial succession with possible implications for ecosystem function

Decreases in Antimicrobial Use Associated With Multihospital Implementation of Electronic Antimicrobial Stewardship Tools.

BackgroundAntimicrobial stewards may benefit from comparative data to inform interventions that promote optimal inpatient antimicrobial use.MethodsAntimicrobial stewards from 8 geographically dispersed Veterans Affairs (VA) inpatient facilities participated in the development of antimicrobial use visualization tools that allowed for comparison to facilities of similar complexity. The visualization tools consisted of an interactive web-based antimicrobial dashboard and, later, a standardized antimicrobial usage report updated at user-selected intervals. Stewards participated in monthly learning collaboratives. The percent change in average monthly antimicrobial use (all antimicrobial agents, anti-methicillin-resistant Staphylococcus aureus [anti-MRSA] agents, and antipseudomonal agents) was analyzed using a pre-post (January 2014-January 2016 vs July 2016-January 2018) design with segmented regression and external comparison with uninvolved control facilities (n = 118).ResultsIntervention sites demonstrated a 2.1% decrease (95% confidence interval [CI], -5.7% to 1.6%) in total antimicrobial use pre-post intervention vs a 2.5% increase (95% CI, 0.8% to 4.1%) in nonintervention sites (absolute difference, 4.6%; P = .025). Anti-MRSA antimicrobial use decreased 11.3% (95% CI, -16.0% to -6.3%) at intervention sites vs a 6.6% decrease (95% CI, -9.1% to -3.9%) at nonintervention sites (absolute difference, 4.7%; P = .092). Antipseudomonal antimicrobial use decreased 3.4% (95% CI, -8.2% to 1.7%) at intervention sites vs a 3.6% increase (95% CI, 0.8% to 6.5%) at nonintervention sites (absolute difference, 7.0%; P = .018).ConclusionsComparative data visualization tool use by stewards at 8 VA facilities was associated with significant reductions in overall antimicrobial and antipseudomonal use relative to uninvolved facilities

Methods for specifying the target difference in a randomised controlled trial : the Difference ELicitation in TriAls (DELTA) systematic review

Peer reviewedPublisher PD

Does Screening for Pain Correspond to High Quality Care for Veterans?

Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear. To assess adherence to measures of pain management quality and identify associated patient and provider factors. A cross-sectional visit-based study. One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients. We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that “patients want me to ask about pain” and “pain can have negative consequences on patient’s functioning”. Charts were more likely to document character of pain if providers agreed that “patients are able to rate their pain”. Patients with musculoskeletal pain were less likely to have chart documentation of character of pain. Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening

Regulatory regionalism and anti-money-laundering governance in Asia

With the intensification of the Financial Action Task Force's (FATF's) worldwide campaign to promote anti-money-laundering regulation since the late 1990s, all Asian states except North Korea have signed up to its rules and have established a regional institution—the Asia/Pacific Group on Money Laundering—to promote and oversee the implementation of FATF's 40 Recommendations in the region. This article analyses the FATF regime, making two key claims. First, anti-money-laundering governance in Asia reflects a broader shift to regulatory regionalism, particularly in economic matters, in that its implementation and functioning depend upon the rescaling of ostensibly domestic agencies to function within a regional governance regime. Second, although this form of regulatory regionalism is established in order to bypass the perceived constraints of national sovereignty and political will, it nevertheless inevitably becomes entangled within the socio-political conflicts that shape the exercise of state power more broadly. Consequently, understanding the outcomes of regulatory regionalism involves identifying how these conflicts shape how far and in what manner global regulations are adopted and implemented within specific territories. This argument is demonstrated by a case study of Myanmar

Impact of instrumentation in lumbar spinal fusion in elderly patients

Background and purpose An increasing number of lumbar fusions are performed using allograft to avoid donor-site pain. In elderly patients, fusion potential is reduced and the patient may need supplementary stability to achieve a solid fusion if allograft is used. We investigated the effect of instrumentation in lumbar spinal fusion performed with fresh frozen allograft in elderly patients

Advanced Technology Large-Aperture Space Telescope (ATLAST): A Technology Roadmap for the Next Decade

The Advanced Technology Large-Aperture Space Telescope (ATLAST) is a set of mission concepts for the next generation of UVOIR space observatory with a primary aperture diameter in the 8-m to 16-m range that will allow us to perform some of the most challenging observations to answer some of our most compelling questions, including "Is there life elsewhere in the Galaxy?" We have identified two different telescope architectures, but with similar optical designs, that span the range in viable technologies. The architectures are a telescope with a monolithic primary mirror and two variations of a telescope with a large segmented primary mirror. This approach provides us with several pathways to realizing the mission, which will be narrowed to one as our technology development progresses. The concepts invoke heritage from HST and JWST design, but also take significant departures from these designs to minimize complexity, mass, or both. Our report provides details on the mission concepts, shows the extraordinary scientific progress they would enable, and describes the most important technology development items. These are the mirrors, the detectors, and the high-contrast imaging technologies, whether internal to the observatory, or using an external occulter. Experience with JWST has shown that determined competitors, motivated by the development contracts and flight opportunities of the new observatory, are capable of achieving huge advances in technical and operational performance while keeping construction costs on the same scale as prior great observatories.Comment: 22 pages, RFI submitted to Astro2010 Decadal Committe