Development of an Abstraction Tool to Assess Palliative Care Components

2021 ◽  
pp. 104990912110617
Author(s):  
Meredith A. MacMartin ◽  
Amber E. Barnato
Keyword(s):  
Palliative Care ◽  
Qualitative Content Analysis ◽  
Medical Center ◽  
Clinical Care ◽  
Academic Medical Center ◽  
Physical Symptoms ◽  
Future Research ◽  
Clinical Documentation ◽  
Cohen’S Kappa ◽  
Cohen's Kappa

Background: Little is known regarding the fidelity of delivery of guideline-recommended components of palliative care in “real world” encounters. Objective: To develop a qualitative coding framework to identify components of clinical palliative care in clinical documentation across care settings. Design: Retrospective review of palliative care clinical documentation from medical providers, with directed qualitative content analysis to identify components of clinical care documented. Setting/Subjects: Purposively sampled deceased patients seen by palliative care at a US academic medical center between 7/1/2011–7/1/2018. Main Outcomes and Measures: The outcome of this work is a coding framework for use in future research. We assessed the robustness of the framework using Cohen’s kappa. Results: We reviewed sixty-two encounters from twenty-six patients. We identified 7 major themes in documentation: (1) addressing physical symptoms, (2) addressing psychological symptoms, (3) establishing illness understanding, (4) supporting decision making, (5) end-of-life planning, (6) understanding psychosocial context, and (7) care coordination. Interrater reliability varied widely between components, with Cohen’s kappa ranging from −.51 to 1. Conclusions: This pilot study provides a coding framework to measure documentation of clinical palliative care components. Several components could not be reliably identified using this framework, suggesting the need for additional measurement strategies.

Palliative Care Services in the NeuroICU: Opportunities and Persisting Barriers

2021 ◽  
pp. 104990912098721
Author(s):  
Michael Morris ◽  
Emily L. Mroz ◽  
Cristina Popescu ◽  
Jacqueline Baron-Lee ◽  
Katharina M. Busl
Keyword(s):  
Palliative Care ◽  
Supportive Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Retrospective Chart Review ◽  
Future Research ◽  
Supportive Services ◽  
Missed Opportunities ◽  
Care Services ◽  
Palliative Care Services

Background: End-of-life (EOL) supportive care, including palliative and hospice services, is an area of increasing importance in critical care. Neurointensivists face unique challenges in providing timely supportive care to terminally ill patients expected to expire in the NeuroICU. Objective: This study explored the extent of effective utilization of, and recorded barriers to, palliative and hospice services in a dedicated 30-bed NeuroICU at a large academic medical center. Design: A retrospective chart review of patients who expired in the NeuroICU was conducted. The timeline from patient admission to arrival of palliative care services was traced. Qualitative review of chart notes was used to identify barriers to provision of palliative services. Setting: A total of 330 patients expired in the NeuroICU during the study period, including 176 from the neurology and 154 from the neurosurgical service. Results: Across services, 146 expired patients were never referred to palliative care or hospice services. Of those referred, over one-third were referred more than 4 days past admission to the NeuroICU. On average, patients were referred with less than 1 day before expiration. Common barriers to referral for supportive services were documented (e.g., patient expected to expire, family declined service). Conclusions: Despite benefits of palliative care and an in-hospital hospice opportunity, we identified lack of referral, and particularly delays in referral to services as significant barriers. Our study highlights these as missed opportunities for patients and families to receive maximum benefits from these services. Future research should solidify triggers for EOL services in this setting.

Amylase and Lipase Co-ordering in the Workup of Pancreatic Disorders Is Unnecessary and Costly: An Institutional Lab Utilization Study

2019 ◽  
Vol 152 (Supplement_1) ◽  
pp. S25-S25
Author(s):  
Meghan Hupp ◽  
Nicholas Peterson ◽  
Sasha Buchner ◽  
Amy B Karger
Keyword(s):  
Acute Pancreatitis ◽  
Medical Center ◽  
Academic Medical Center ◽  
Cost Savings ◽  
The United States ◽  
Cohen’S Kappa ◽  
Cohen's Kappa ◽  
Meta Analyses ◽  
Lab Test ◽  
Evidence Based Guidelines

Abstract Background Acute pancreatitis is the most common gastrointestinal cause of hospitalization in the United States. Amylase and lipase are commonly ordered together in the workup of suspected pancreatitis at our institution (a large academic medical center), despite meta-analyses and evidence-based guidelines that recommend the use of lipase alone. Lipase has more diagnostic accuracy, rises earlier, and stays elevated longer than amylase. Co-ordering amylase has not been shown to increase sensitivity or specificity. This study aims to explore how well amylase and lipase correlate in our patient population, and which marker more accurately detects acute pancreatitis when the results are discrepant. Methods The laboratory information system was queried for co-orders of amylase and lipase during a 2-month period (November 1, 2016, to December 31, 2016). The overall agreement and Cohen’s kappa were calculated. Discrepant results were separated from concordant results. Clinical data were extracted from the electronic medical record, including the rationale for ordering and relevant diagnosis code. Results There were 962 instances of amylase and lipase co-orders in the 2-month period. Of these, 138 had high amylase and lipase, and 694 had normal amylase and lipase concentrations. The overall agreement was 86.5% and Cohen’s kappa was 0.596 (moderate agreement) (P < .0001). There were 88 cases in which the lipase was elevated and the amylase was normal. Of these, 12 were acute pancreatitis and 76 were not. There were 42 cases in which the amylase was elevated and the lipase was normal; only one case out of 42 was acute pancreatitis. Further investigation into this case revealed that the patient was approximately 7 months status-post pancreas transplant. During this admission, he was diagnosed with “graft pancreatitis” and, while amylase remained elevated above the reference range for longer than lipase after treatment, both enzymes were increased at diagnosis (lipase 831 U/L [73-393 U/L] and amylase 194 U/L [30-110 U/L]). These data show that, had only lipase been ordered, no cases of acute pancreatitis would have been missed. Conclusion Amylase has been shown to be an inferior marker of acute pancreatitis compared to lipase, and many guidelines recommend the use of lipase alone. However, these tests are commonly co-ordered at our institution; in a given 2-month period, there were 962 co-order events. Of these, there were no cases of pancreatitis that would have been missed by ordering lipase alone. Our laboratory charges $50 per amylase assay; therefore $48,100 was spent on unnecessary amylase orders during the 2 months of this study. Lab test overutilization has been identified as an important problem; if addressed and curtailed, labs and hospitals can increase efficiency and cost savings.

scholarly journals Risk factors associated with physician trainee concern over missed educational opportunities during the COVID-19 pandemic

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Sunny S. Lou ◽  
Charles W. Goss ◽  
Bradley A. Evanoff ◽  
Jennifer G. Duncan ◽  
Thomas Kannampallil
Keyword(s):  
Risk Factors ◽  
Clinical Education ◽  
Medical Center ◽  
Clinical Care ◽  
Academic Medical Center ◽  
Clinical Work ◽  
Educational Opportunities ◽  
Missed Opportunities ◽  
Physician Trainee ◽  
At Home

Abstract Background The COVID-19 pandemic resulted in a transformation of clinical care practices to protect both patients and providers. These changes led to a decrease in patient volume, impacting physician trainee education due to lost clinical and didactic opportunities. We measured the prevalence of trainee concern over missed educational opportunities and investigated the risk factors leading to such concerns. Methods All residents and fellows at a large academic medical center were invited to participate in a web-based survey in May of 2020. Participants responded to questions regarding demographic characteristics, specialty, primary assigned responsibility during the previous 2 weeks (clinical, education, or research), perceived concern over missed educational opportunities, and burnout. Multivariable logistic regression was used to assess the relationship between missed educational opportunities and the measured variables. Results 22% (301 of 1375) of the trainees completed the survey. 47% of the participants were concerned about missed educational opportunities. Trainees assigned to education at home had 2.85 [95%CI 1.33–6.45] greater odds of being concerned over missed educational opportunities as compared with trainees performing clinical work. Trainees performing research were not similarly affected [aOR = 0.96, 95%CI (0.47–1.93)]. Trainees in pathology or radiology had 2.51 [95%CI 1.16–5.68] greater odds of concern for missed educational opportunities as compared with medicine. Trainees with greater concern over missed opportunities were more likely to be experiencing burnout (p = 0.038). Conclusions Trainees in radiology or pathology and those assigned to education at home were more likely to be concerned about their missed educational opportunities. Residency programs should consider providing trainees with research or at home clinical opportunities as an alternative to self-study should future need for reduced clinical hours arise.

scholarly journals Static Ankle Dorsiflexion and Hip and Pelvis Kinematics During Forward Step-Down in Patients With Hip-Related Groin Pain

2020 ◽  
pp. 1-8
Author(s):  
Stefanie N. Foster ◽  
Michael D. Harris ◽  
Mary K. Hastings ◽  
Michael J. Mueller ◽  
Gretchen B. Salsich ◽  
...  
Keyword(s):  
Pelvic Tilt ◽  
Groin Pain ◽  
Medical Center ◽  
Weight Bearing ◽  
Academic Medical Center ◽  
Ankle Dorsiflexion ◽  
Future Research ◽  
Cross Sectional ◽  
Anterior Pelvic Tilt ◽  
Step Down

Context: The authors hypothesized that in people with hip-related groin pain, less static ankle dorsiflexion could lead to compensatory hip adduction and contralateral pelvic drop during step-down. Ankle dorsiflexion may be a modifiable factor to improve ability in those with hip-related groin pain to decrease hip/pelvic motion during functional tasks and improve function. Objective: To determine whether smaller static ankle dorsiflexion angles were associated with altered ankle, hip, and pelvis kinematics during step-down in people with hip-related groin pain. Design: Cross-sectional Setting: Academic medical center. Patients: A total of 30 people with hip-related groin pain (12 males and 18 females; 28.7 [5.3] y) participated. Intervention: None. Main Outcome Measures: Weight-bearing static ankle dorsiflexion with knee flexed and knee extended were measured via digital inclinometer. Pelvis, hip, and ankle kinematics during forward step-down were measured via 3D motion capture. Static ankle dorsiflexion and kinematics were compared with bivariate correlations. Results: Smaller static ankle dorsiflexion angles were associated with smaller ankle dorsiflexion angles during the step-down for both the knee flexed and knee extended static measures. Among the total sample, smaller static ankle dorsiflexion angle with knee flexed was associated with greater anterior pelvic tilt and greater contralateral pelvic drop during the step-down. Among only those who did not require a lowered step for safety, smaller static ankle dorsiflexion angles with knee flexed and knee extended were associated with greater anterior pelvic tilt, greater contralateral pelvic drop, and greater hip flexion. Conclusions: Among those with hip-related groin pain, smaller static ankle dorsiflexion angles are associated with less ankle dorsiflexion motion and altered pelvis and hip kinematics during a step-down. Future research is needed to assess the effect of treating restricted ankle dorsiflexion on quality of motion and symptoms in patients with hip-related groin pain.

scholarly journals Voice-Based Screening For SARS-CoV-2 Exposure In Cardiovascular Clinics

2021 ◽  
Author(s):  
Abhinav Sharma ◽  
Emily Oulousian ◽  
Jiayi Ni ◽  
Renato Lopes ◽  
Matthew Pellan Cheng ◽  
...  
Keyword(s):  
Healthcare Provider ◽  
Clinical Care ◽  
Health Centre ◽  
Healthcare Delivery ◽  
Signs And Symptoms ◽  
Kappa Statistic ◽  
Cohen’S Kappa ◽  
Cohen's Kappa ◽  
Mcgill University ◽  
Strongly Agree

Abstract Aims Artificial intelligence (A.I) driven voice-based assistants may facilitate data capture in clinical care and trials; however, the feasibility and accuracy of using such devices in a healthcare environment are unknown. We explored the feasibility of using the Amazon Alexa (‘Alexa’) A.I. voice-assistant to screen for risk-factors or symptoms relating to SARS-CoV-2 exposure in quaternary care cardiovascular clinics. Methods We enrolled participants to be screened for signs and symptoms of SARS-CoV-2 exposure by a healthcare provider and then subsequently by the Alexa. Our primary outcome was interrater reliability of Alexa to healthcare provider screening using Cohen’s Kappa statistic. Participants rated the Alexa in a post-study survey (scale of 1 to 5 with 5 reflecting strongly agree). This study was approved by the McGill University Health Centre ethics board. Results We prospectively enrolled 215 participants. The mean age was 46 years (17.7 years standard deviation [SD]), 55% were female, and 31% were French speakers (others were English). In total, 645 screening questions were delivered by Alexa. The Alexa mis-identified one response. The simple and weighted Cohen’s kappa statistic between Alexa and healthcare provider screening was 0.989 (95% CI: 0.982, 0.997) and 0.992 (955 CI 0.985, 0.999) respectively. The participants gave an overall mean rating of 4.4 (out of 5, 0.9 SD). Conclusion Our study demonstrates the feasibility of an A.I. driven multilingual voice-based assistant to collect data in the context of SARS-CoV-2 exposure screening. Future studies integrating such devices in cardiovascular healthcare delivery and clinical trials are warranted. Registration https://clinicaltrials.gov/ct2/show/NCT04508972

scholarly journals Preparing Clinical Text for Use in Biomedical Research

2011 ◽  
pp. 2085-2095
Author(s):  
John P. Pestian ◽  
Lukasz Itert ◽  
Charlotte Andersen
Keyword(s):  
Language Processing ◽  
Medical Center ◽  
Clinical Care ◽  
Academic Medical Center ◽  
Clinical Text ◽  
Delivery Of Care ◽  
Radiology Reports ◽  
Academic Medical ◽  
Textual Data ◽  
Regulatory Actions

Approximately 57 different types of clinical annotations construct a patient’s medical record. These annotations include radiology reports, discharge summaries, and surgical and nursing notes. Hospitals typically produce millions of text-based medical records over the course of a year. These records are essential for the delivery of care, but many are underutilized or not utilized at all for clinical research. The textual data found in these annotations is a rich source of insights into aspects of clinical care and the clinical delivery system. Recent regulatory actions, however, require that, in many cases, data not obtained through informed consent or data not related to the delivery of care must be made anonymous (as referred to by regulators as harmless), before they can be used. This article describes a practical approach with which Cincinnati Children’s Hospital Medical Center (CCHMC), a large pediatric academic medical center with more than 761,000 annual patient encounters, developed open source software for making pediatric clinical text harmless without losing its rich meaning. Development of the software dealt with many of the issues that often arise in natural language processing, such as data collection, disambiguation, and data scrubbing.

scholarly journals An overview of radiological manifestations of acquired dental developmental disturbances in paediatric head and neck cancer survivors

2020 ◽  
Vol 49 (3) ◽  
pp. 20190275
Author(s):  
Reinier C. Hoogeveen ◽  
Marinka L.F. Hol ◽  
Bradley R. Pieters ◽  
Brian V. Balgobind ◽  
Erwin W.E.R. Berkhout ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Cancer Survivors ◽  
Head And Neck ◽  
Developmental Disorders ◽  
Medical Center ◽  
Academic Medical Center ◽  
Future Research ◽  
Dental Development ◽  
Radiographic Findings ◽  
Anterior Teeth

Objectives: In paediatric cancer survivors treated with chemotherapy and radiotherapy therapy, late effects on dental development are quite common. Oral radiologists are not familiar with the radiographic images of these specific dental consequences of chemotherapy and radiotherapy. With the goal of educating colleagues, to raise awareness of the needs of survivors, and to identify directions for future research, we present dental radiographs of survivors treated for head and neck rhabdomyosarcoma with chemotherapy and radiotherapy. Also, based on the survivors reviewed, a radiographic inventory of commonly found late dental developmental effects seen in conjunction with treatment is presented. Methods: Panoramic radiographic findings of five illustrative cases are presented, from a group of 42 survivors of head and neck rhabdomyosarcoma treated at the Academic Medical Center Amsterdam, The Netherlands over the past 25 years. Results: Five cases showing dental developmental disorders are presented. These cases show an association of the location of the radiation field and the developmental stage of the teeth with the severity of the effect on dental development. We also report an inventory of severe and moderate effects of chemotherapy and radiotherapy on the development of molars and anterior teeth. Conclusions: This paper presents five cases and a radiographic inventory to illustrate disturbances of dental development associated with chemotherapy and radiotherapy in children. Medical and dental professionals involved in the treatment of cancer survivors are relatively unaware of the dental consequences of radiation therapy and the age dependency of specific regional effects. These effects can be severe, with great impact on quality of life. Further research in this area could help improve planning of radiation therapy for children, potentially preventing or limiting dental or maxillofacial sequelae.

scholarly journals Navigating Tensions: Integrating Palliative Care Consultation Services Into an Academic Medical Center Setting

2011 ◽  
Vol 42 (5) ◽  
pp. 680-690 ◽  
Author(s):  
Sally A. Norton ◽  
Bethel Ann Powers ◽  
Madeline H. Schmitt ◽  
Maureen Metzger ◽  
Eileen Fairbanks ◽  
...  
Keyword(s):  
Palliative Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Palliative Care Consultation ◽  
Academic Medical ◽  
Care Consultation ◽  
Consultation Services

Usefulness of the Surprise Question on an Inpatient Oncology Service

2018 ◽  
Vol 35 (11) ◽  
pp. 1421-1425 ◽  
Author(s):  
Sarguni Singh ◽  
Adrian Rodriguez ◽  
Darrell Lee ◽  
Sung-Joon Min ◽  
Stacy Fischer
Keyword(s):  
Palliative Care ◽  
Medical Center ◽  
Academic Medical Center ◽  
Hospital Medicine ◽  
Medical Setting ◽  
Improvement Project ◽  
Care Clinic ◽  
Oncology Service ◽  
Multidisciplinary Rounds ◽  
Surprise Question

Background: Prognostication of survival in patients with advanced cancer has been challenging and contributes to poor illness understanding. Prognostic disagreement occurs even among providers and is a less studied phenomenon. Objective: We introduced the surprise question (SQ), “Would I be surprised if this patient died in the next 1 year, 6 months, and 1 month?,” at multidisciplinary rounds to increase palliative care referrals through the introduction of this prognostic prompt. Design, Setting, Patients: This quality improvement project took place from March 2016 to May 2016 on the medical oncology service at a tertiary academic medical center. The question was asked 3 times a week at multidisciplinary rounds which are attended by the hospital medicine provider, palliative care provider, and consulting oncologist. Primary oncologists and bedside nurses were also asked the SQ. Measurements: Referral rates to outpatient palliative care clinic, community-based palliative care clinic, inpatient palliative care consults, and hospice 3 months prior to, during, and 5 months postintervention. Results: Regular discussion of prognosis of patients with cancer in an inpatient medical setting did not increase referrals to inpatient or outpatient palliative care or hospice. Increased clinical experience impacted hospital medicine providers and bedside nurses’ estimation of prognosis differently than oncology providers. Medical oncologists were significantly more optimistic than hospital medicine providers.

Implementing clinic to home telehealth services to promote quality of life for ambulatory oncology palliative care patients.

2020 ◽  
Vol 38 (29_suppl) ◽  
pp. 259-259
Author(s):  
Megan Begnoche ◽  
Dana Guyer ◽  
Susan F. Korber ◽  
Mary Anne Fenton
Keyword(s):  
Palliative Care ◽  
Behavioral Health ◽  
Role Models ◽  
Hospital Admissions ◽  
Medical Center ◽  
Academic Medical Center ◽  
Community Partner ◽  
Home Setting ◽  
Ambulatory Oncology ◽  
Home Telehealth

259 Background: The Lifespan Cancer Institute (LCI) identified strategies to improve the palliative care experience and outcomes by providing clinic to home telehealth services. LCI is an integrated academic medical center program combining three hospital programs operating at five outpatient sites. One quality goal is to embed and increase palliative care within the fabric of oncology by providing palliative telehealth in the home to avoid office visits, ED and hospital admissions. Methods: LCI’s multidisciplinary palliative care team, including administrators, physicians, advanced practice providers and community partner physicians assessed telehealth challenges with a vulnerable patient in the home setting. Process development included operations, technology, patient and staff education. The group modified existing Lifespan system workflows, clinic to clinic video for behavioral health and clinic to clinic for providers, to create the clinic to home method. This process benchmarked patient and behavioral health noting video differences with the clinic setting versus the home. Results: Outcome metrics include no show rate, chemotherapy within 14 days of death, ED/ICU within 30 days of death, patient and provider experience. Initial data shows no show rates decreased from 10% (January) to 6% (May) as telehealth increased. Patients marked deceased within 3 months of a LCI visit for January (n = 52) and May ( = 61) unfortunately did not have a negative trend for chemotherapy in the last 14 days of life (Jan: 8%, May 15%). ED and ICU visits both had modest decreases from January (ED 50%, ICU 29%) to May (ED 48%, ICU 21%). In anticipation of future Press Ganey results, patient feedback includes an increase of comfort while at home. Provider satisfaction increased with the ability to assess the patient in their own home instead of the sterile clinic environment. Encountered challenges include insurance restrictions for Rhode Island (not a rural state), technology, and remote trouble shooting. Conclusions: The success of clinic-to-home telehealth services set the foundation for the COVID-19 telehealth insurgence and led to the palliative team acting as role models to medical and radiation oncology. End of life oncology patients stayed home while having their palliative needs addressed remotely. The innovative approach to implementing telehealth services will serve as a model for future LCI telehealth programs including treatment education sessions, oral chemotherapy follow-up, survivorship and post hospital discharge assessments.

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