Prior data have suggested that suboptimal antibiotic prescribing in the emergency department (ED) is common for uncomplicated lower respiratory tract infections (LRTI), urinary tract infections ...(UTI), and acute bacterial skin and skin structure infections (ABSSSI). The objective of this study was to measure the effect of indication-based antibiotic order sentences (AOS) on optimal antibiotic prescribing in the ED.
This was an IRB-approved quasi-experiment of adults prescribed antibiotics in EDs for uncomplicated LRTI, UTI, or ABSSSI from January to June 2019 (pre-implementation) and September to December 2021 (post-implementation). AOS implementation occurred in July 2021. AOS are lean process, electronic discharge prescriptions retrievable by name or indication within the discharge order field. The primary outcome was optimal prescribing, defined as correct antibiotic selection, dose, and duration per local and national guidelines. Descriptive and bivariate statistics were performed; multivariable logistic regression was used to determine variables associated with optimal prescribing.
A total of 294 patients were included: 147 pre-group and 147 post-group. Overall optimal prescribing improved from 12 (8%) to 34 (23%) (P < 0.001). Individual components of optimal prescribing were optimal selection at 90 (61%) vs 117 (80%) (P < 0.001), optimal dose at 99 (67%) vs 115 (78%) (P = 0.036), and optimal duration at 38 (26%) vs 50 (34%) (P = 0.13) for pre- and post-group, respectively. AOS was independently associated with optimal prescribing after multivariable logistic regression analysis (adjOR, 3.6; 95%CI,1.7–7.2). A post-hoc analysis showed low uptake of AOS by ED prescribers.
AOS are an efficient and promising strategy to enhance antimicrobial stewardship in the ED.
The cumulative load of genetic predisposition, early life adversity (ELA) and lifestyle shapes the prevalence of psychiatric disorders. Single nucleotide polymorphisms (SNPs) in the human FKBP5 gene ...were shown to modulate disease risk. To enable investigation of disease-related SNPs in behaviourally relevant context, we generated humanised mouse lines carrying either the risk (AT) or the resiliency (CG) allele of the rs1360780 locus and exposed litters of these mice to maternal separation. Behavioural and physiological aspects of their adult stress responsiveness displayed interactions of genotype, early life condition, and sex. In humanised females carrying the CG- but not the AT-allele, ELA led to altered HPA axis functioning, exploratory behaviour, and sociability. These changes correlated with differential expression of genes in the hypothalamus, where synaptic transmission, metabolism, and circadian entrainment pathways were deregulated. Our data suggest an integrative role of FKBP5 in shaping the sex-specific outcome of ELA in adulthood.
Objective
Assessing the diversity, equity, and inclusion (DEI) climate of emergency departments (EDs) can inform organizational change to provide equitable, inclusive, and high‐quality care to their ...diverse patient populations. The purpose of this project was to investigate patient perspectives on the climate of DEI in an urban ED.
Methods
This was a cross‐sectional survey study conducted in a large‐volume, urban ED in Detroit, MI, from November 2018 to January 2019. The survey was developed by an experienced ED DEI committee via an iterative process and broad consensus.
Results
During their care in the ED, 849 patients completed an anonymous survey about their perspectives and experiences of DEI in that ED. Overall, the responses were favorable as most respondents reported that the ED staff treated patients from all races equally (75.8%) and made patients feel accepted (86%). However, some respondents felt that the ED staff's treatment of populations with greater complexity, such as patients who are mentally ill (16.8%) or lower income (14.3%), needs the most improvement.
Conclusions
This DEI climate assessment survey of ED patients’ perspectives revealed important insights that could guide strategic initiatives to advance DEI in the ED. This assessment may serve as a model for continuous evaluation of DEI over time and in multiple healthcare settings to help guide organizational change efforts.
Background: The Accreditation Council for Graduate Medical Education (ACGME) introduced milestones for Emergency Medicine (EM) in 2012. Clinical Competency Committees (CCC) are tasked with assessing ...residents on milestones and reporting them to the ACGME. Appropriate workflows for CCCs are not well defined.
Objective: Our objective was to compare different approaches to milestone assessment by a CCC, quantify resource requirements for each and to identify the most efficient workflow.
Design: Three distinct processes for rendering milestone assessments were compared:
Full milestone assessments (FMA) utilizing all available resident assessment data,
Ad-hoc milestone assessments (AMA) created by multiple expert educators using their personal assessment of resident performance,
Self-assessments (SMA) completed by residents.
FMA were selected as the theoretical gold standard. Intraclass correlation coefficients were used to analyze for agreement between different assessment methods. Kendall's coefficient was used to assess the inter-rater agreement for the AMA.
Results: All 13 second-year residents and 7 educational faculty of an urban EM Residency Program participated in the study in 2013. Substantial or better agreement between FMA and AMA was seen for 8 of the 23 total subcompetencies (PC4, PC8, PC9, PC11, MK, PROF2, ICS2, SBP2), and for 1 subcompetency (SBP1) between FMA and SMA. Multiple AMA for individual residents demonstrated substantial or better interobserver agreement in 3 subcompetencies (PC1, PC2, and PROF2). FMA took longer to complete compared to AMA (80.9 vs. 5.3 min, p < 0.001).
Conclusions: Using AMA to evaluate residents on the milestones takes significantly less time than FMA. However, AMA and SMA agree with FMA on only 8 and 1 subcompetencies, respectively. An estimated 23.5 h of faculty time are required each month to fulfill the requirement for semiannual reporting for a residency with 42 trainees.
The HESI-led RISK21 effort has developed a framework supporting the use of twenty-first century technology in obtaining and using information for chemical risk assessment. This framework represents a ...problem formulation-based, exposure-driven, tiered data acquisition approach that leads to an informed decision on human health safety to be made when sufficient evidence is available. It provides a transparent and consistent approach to evaluate information in order to maximize the ability of assessments to inform decisions and to optimize the use of resources. To demonstrate the application of the framework's roadmap and matrix, this case study evaluates a large number of chemicals that could be present in drinking water. The focus is to prioritize which of these should be considered for human health risk as individual contaminants. The example evaluates 20 potential drinking water contaminants, using the tiered RISK21 approach in combination with graphical representation of information at each step, using the RISK21 matrix. Utilizing the framework, 11 of the 20 chemicals were assigned low priority based on available exposure data alone, which demonstrated that exposure was extremely low. The remaining nine chemicals were further evaluated, using refined estimates of toxicity based on readily available data, with three deemed high priority for further evaluation. In the present case study, it was determined that the greatest value of additional information would be from improved exposure models and not from additional hazard characterization.
The aim of this study was to determine the effect of a clinical education initiative on the appropriate utilization of screening cervical spine CT in the emergency department. The purpose was to ...assess if clinical education can produce stricter adherence to the ACR Appropriateness Criteria and improve the utilization of screening CT examinations in the emergency department.
Institutional review board approval was obtained for this HIPAA-compliant study. All adult patients presenting to a level 1 trauma center with blunt trauma prompting screening cervical spine CT were eligible. For each study, the requesting clinician completed a survey selecting all clinical indications. CT examinations were evaluated by a board-certified radiologist blinded to survey data. Results were compared with retrospective and prospective studies performed before the institution of the education initiative.
Of the 388 cervical spine CT examinations performed, 12 (3.1%) were positive for acute cervical spine injury, compared to only 1.0% before the clinical education program (phase 2). Of the 376 examinations without injury, 13% met all 5 National Emergency X-Radiography Utilization Study criteria for nonimaging (down from 16.1% in phase 2), and 15 (4%) required no imaging when both National Emergency X-Radiography Utilization Study and abbreviated Canadian cervical spine rule criteria were applied.
Implementation of a clinical education initiative resulted in improved adherence to ACR Appropriateness Criteria and improved clinical effectiveness of the studies by increasing fracture detection rate. Initiatives such as these could potentially influence imaging overutilization without burdening emergency department clinicians with excessive roadblocks to image ordering.
Emerging known and unknown pathogens create profound threats to public health. Platforms for rapid detection and characterization of microbial agents are critically needed to prevent and respond to ...disease outbreaks. Available detection technologies cannot provide broad functional information about known or novel organisms. As a step toward developing such a system, we have produced and tested a series of high-density functional gene arrays to detect elements of virulence and antibiotic resistance mechanisms. Our first generation array targets genes from Escherichia coli strains K12 and CFT073, Enterococcus faecalis and Staphylococcus aureus. We determined optimal probe design parameters for gene family detection and discrimination. When tested with organisms at varying phylogenetic distances from the four target strains, the array detected orthologs for the majority of targeted gene families present in bacteria belonging to the same taxonomic family. In combination with whole-genome amplification, the array detects femtogram concentrations of purified DNA, either spiked in to an aerosol sample background, or in combinations from one or more of the four target organisms. This is the first report of a high density NimbleGen microarray system targeting microbial antibiotic resistance and virulence mechanisms. By targeting virulence gene families as well as genes unique to specific biothreat agents, these arrays will provide important data about the pathogenic potential and drug resistance profiles of unknown organisms in environmental samples.
When engineering and computing activities are solely electives, extra curriculars, or informal learning activities, student participation is limited by self-selection. By integrating technological ...projects into required coursework, all students gain exposure. The Arts & Bots Math and Science Partnership integrates creative robotics into middle school classes such as English and history as transdisciplinary, creative robotics projects. We discuss two case studies of such projects, describing how teachers developed projects through sequential implementations; and how project instruction focuses on developing student technological fluency, collaboration, and understanding of class content. One case study describes the integration of Arts & Bots into 7th and 8th grade English Language Arts in which students build robotic sculptures that represent a poem or scene in a play. The second case study describes a 7th grade Health and Physical Education project in which students build models of human joints and limbs in order to understand muscle pairs. We discuss differences, themes, and best practices for integration of creative robotics into non-technical classes through a comparison of projects implemented to date. The case studies are supplemented by data from student (N=195) and teacher (N=6) evaluations.
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