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Journal of Graduate Medical Education Dec 2017Some residency programs responded to duty hour restrictions by implementing night rotations. Night supervision models can vary, resulting in potential patient safety...
BACKGROUND
Some residency programs responded to duty hour restrictions by implementing night rotations. Night supervision models can vary, resulting in potential patient safety issues and educational voids for residents.
OBJECTIVE
We evaluated the impact of multiple evidence-based interventions on resident satisfaction with supervision, perception of the education value of night rotations, and residents' use of online educational materials.
METHODS
The night team was augmented with an intern to assist with admissions and a senior resident (the "nighthawk") to supervise inpatient care and deliver a night medicine curriculum. We instituted a "must-call" list, with specific clinical events requiring mandatory attending notification, and reduced conflict in the role of the night float team. We studied patient contact, online curriculum use, residents' perceptions of nighthawk involvement, exposure to educational materials, and satisfaction with supervision.
RESULTS
During the first half of academic year 2016-2017, 51% (64 of 126) of trainees were on the night medicine rotation. The nighthawk reviewed 1007 intern plans (15 per night; range, 6-36) and supervised 215 hands-on evaluations, including codes and rapid responses (3 per night; range, 0-12). The number of users of the online education materials increased by 85% (13 to 24), and instances of use increased 35% (85 to 115). The majority of residents (79%, 27 of 34) favored the new system.
CONCLUSIONS
A nighthawk rotation, a must-call list, and reducing conflict in night team members' roles improved resident satisfaction with supervision and the night medicine rotation, resulting in increased communication.
Topics: Attitude of Health Personnel; Computer-Assisted Instruction; Curriculum; Education, Medical, Graduate; Humans; Internship and Residency; Job Satisfaction; Night Care; Patient Care Team; Patient Safety; Personnel Staffing and Scheduling; Work Schedule Tolerance
PubMed: 29270267
DOI: 10.4300/JGME-D-17-00259.1 -
PloS One 2014Updated estimates of measles case fatality rates (CFR) are critical for monitoring progress towards measles elimination goals. India accounted for 36% of total measles...
BACKGROUND
Updated estimates of measles case fatality rates (CFR) are critical for monitoring progress towards measles elimination goals. India accounted for 36% of total measles deaths occurred globally in 2011. We conducted a retrospective cohort study to estimate measles CFR and identify the risk factors for measles death in Bihar-one of the north Indian states historically known for its low vaccination coverage.
METHODS
We systematically selected 16 of the 31 laboratory-confirmed measles outbreaks occurring in Bihar during 1 October 2011 to 30 April 2012. All households of the villages/urban localities affected by these outbreaks were visited to identify measles cases and deaths. We calculated CFR and used multivariate analysis to identify risk factors for measles death.
RESULTS
The survey found 3670 measles cases and 28 deaths (CFR: 0.78, 95% confidence interval: 0.47-1.30). CFR was higher among under-five children (1.22%) and children belonging to scheduled castes/tribes (SC/ST, 1.72%). On multivariate analysis, independent risk factors associated with measles death were age <5 years, SC/ST status and non-administration of vitamin A during illness. Outbreaks with longer interval between the occurrence of first case and notification of the outbreak also had a higher rate of deaths.
CONCLUSIONS
Measles CFR in Bihar was low. To further reduce case fatality, health authorities need to ensure that SC/ST are targeted by the immunization programme and that outbreak investigations target for vitamin A treatment of cases in high risk groups such as SC/ST and young children and ensure regular visits by health-workers in affected villages to administer vitamin A to new cases.
Topics: Age Factors; Child; Child, Preschool; Disease Outbreaks; Female; Humans; Immunization Programs; India; Infant; Male; Measles; Measles Vaccine; Retrospective Studies; Risk Factors; Socioeconomic Factors; Survival Rate
PubMed: 24824641
DOI: 10.1371/journal.pone.0096668 -
American Journal of Kidney Diseases :... Jul 2015There are more than 325 living kidney donors who have developed end-stage renal disease and have been listed on the Organ Procurement and Transplantation Network...
There are more than 325 living kidney donors who have developed end-stage renal disease and have been listed on the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) deceased donor kidney wait list. The OPTN/UNOS database records where these kidney donors are listed and, if they donated after April 1994, where that donation occurred. These 2 locations are often not the same. In this commentary, I examine whether a national living donor registry should be created and whether transplantation centers should be notified when one of their living kidney donors develops end-stage renal disease. I consider and refute 5 potential objections to center notification. I explain that transplantation centers should look back at these cases and input data into a registry to attempt to identify patterns that could improve donor evaluation protocols. Creating a registry and mining the information it contains is, in my view, our moral and professional responsibility to future patients and the transplantation endeavor. As individuals and as a community, we need to acknowledge the many unknown risks of living kidney donation and take responsibility for identifying these risks. We then must share information about these risks, educate prospective donors about them, and attempt to minimize them.
Topics: Donor Selection; Humans; Kidney Failure, Chronic; Kidney Transplantation; Living Donors; Registries; Risk; Tissue and Organ Procurement; Waiting Lists
PubMed: 25936672
DOI: 10.1053/j.ajkd.2015.01.032 -
JMIR Formative Research Sep 2018Approximately 10% of adolescents in the United States have asthma. Adolescents widely use apps on mobile phones and tablet technology for social networking and gaming...
BACKGROUND
Approximately 10% of adolescents in the United States have asthma. Adolescents widely use apps on mobile phones and tablet technology for social networking and gaming purposes. Given the increase in recreational app use among adolescents, leveraging apps to support adolescent asthma disease management seems warranted. However, little empirical research has influenced asthma app development; adolescent users are seldom involved in the app design process.
OBJECTIVE
The aim of this mixed-methods study was to assess adolescent preferences and design recommendations for an asthma self-management app.
METHODS
A total of 20 adolescents with persistent asthma (aged 12-16 years) provided feedback on two asthma self-management apps during in-person semistructured interviews following their regularly scheduled asthma clinic visit and via telephone 1 week later. Interviews were audiorecorded, transcribed verbatim, analyzed using SPSS v24, and coded thematically using MAXQDA 11.
RESULTS
Regarding esthetics, app layout and perceived visual simplicity were important to facilitate initial app use. Adolescents were more likely to continually engage with apps that were deemed useful and met their informational needs. Adolescents also desired app features that fit within their existing paradigm or schema and included familiar components (eg, medication alerts that appear and sound like FaceTime notifications and games modeled after Quiz Up and Minecraft), as well as the ability to customize app components. They also suggested that apps include other features, such as an air quality tracker and voice command.
CONCLUSIONS
Adolescents desire specific app characteristics including customization and tailoring to meet their asthma informational needs. Involving adolescents in early stages of app development is likely to result in an asthma app that meets their self-management needs and design preferences and ultimately the adoption and maintenance of positive asthma self-management behaviors.
PubMed: 30684424
DOI: 10.2196/10055 -
Human Vaccines & Immunotherapeutics Mar 2020In Hong Kong, universal varicella vaccination was introduced in July 2014 with a two-dose schedule but the vaccines had been available in the private market since 1996....
In Hong Kong, universal varicella vaccination was introduced in July 2014 with a two-dose schedule but the vaccines had been available in the private market since 1996. With data from varicella notification and surveys on immunization coverage, we used the screening method to estimate dose-specific varicella vaccine effectiveness (VE) among preschool children in Hong Kong before universal vaccination. We estimated the VE of one- and two-dose varicella vaccination against all notified varicella as 69.4% (95% confidence interval (95% CI) 69.5-71.2) and 93.4% (95% CI 91.7-94.7), respectively. We found that VE did not decrease with time since receipt. Varicella vaccine was more effective against complications (85.4% [95% CI 48.8-95.8] for one dose and 100% [95% CI -Inf to 100] for two doses) and against hospital admission (75.2% [95% CI 53.4-86.8] for one dose and 93.1% [95% CI 47.1-99.1] for two doses). Lower protection of one-dose varicella vaccine resulted in breakthrough varicella. Under universal vaccination, second-dose varicella vaccine (given as combined measles, mumps, rubella and varicella vaccine) was first scheduled for children when they reach primary one (about 6 years of age) and was recently advanced to 18 months of age. Shortening the interval between the first dose and second dose of varicella vaccination should reduce breakthrough varicella and outbreaks in preschool.
Topics: Chickenpox; Chickenpox Vaccine; Child, Preschool; Hong Kong; Humans; Immunization Schedule; Infant; Measles-Mumps-Rubella Vaccine; Mumps; Vaccination; Vaccines, Combined
PubMed: 31642729
DOI: 10.1080/21645515.2019.1663121 -
Global Health, Science and Practice Dec 2021Eleven anti-TB drugs were included in the Government of India's Schedule H1 drug regulations in 2014. The National Strategic Plan for TB Elimination in India 2017-2025...
INTRODUCTION
Eleven anti-TB drugs were included in the Government of India's Schedule H1 drug regulations in 2014. The National Strategic Plan for TB Elimination in India 2017-2025 recognized the opportunity to strengthen the TB surveillance system and improve the quality of TB care by implementing the Schedule H1 regulation. However, there were no documented systematic large-scale efforts to use Schedule H1 regulation to support TB surveillance or improve the quality of care. We aimed to document the process of implementation of the Schedule H1 regulation to enhance the quality of TB care and strengthen the TB surveillance system in Kerala, India.
METHODS
We conducted 33 in-depth interviews of the drugs control department enforcement officers, chemist shop owners, private-sector doctors, leaders of professional medical associations, and program managers and key staff of the TB Elimination Program in Kerala. Major themes identified were the process of implementation of Schedule H1 and how the National TB Elimination Program used the information. Findings from the qualitative interviews were corroborated with the quantitative information from the annual program performance reports and anti-TB drug sales data.
RESULTS
The TB Elimination Program of Kerala used the information from the Schedule H1 drug register to identify the missing TB cases and strengthen TB notification, identify providers for engagement and extend support to them for ensuring standards of TB care, and provide feedback to providers regarding prescription practices. Stakeholders felt that implementation of Schedule H1 surveillance has helped to improve TB patient notifications from the private sector, build better public-private partnerships, and improve the quality of TB diagnosis and treatment in Kerala.
CONCLUSION
Pharmacy-based drug sales data collected either through regulatory or non-regulatory methods have immense potential to support TB elimination programs.
Topics: Humans; India; Pharmacies; Pharmacy; Private Sector; Public-Private Sector Partnerships; Tuberculosis
PubMed: 34933980
DOI: 10.9745/GHSP-D-21-00346 -
PLoS Medicine Aug 2021There is limited empiric evidence on the coverage of pneumococcal conjugate vaccines (PCVs) required to generate substantial indirect protection. We investigate the... (Observational Study)
Observational Study
Levels of pneumococcal conjugate vaccine coverage and indirect protection against invasive pneumococcal disease and pneumonia hospitalisations in Australia: An observational study.
BACKGROUND
There is limited empiric evidence on the coverage of pneumococcal conjugate vaccines (PCVs) required to generate substantial indirect protection. We investigate the association between population PCV coverage and indirect protection against invasive pneumococcal disease (IPD) and pneumonia hospitalisations among undervaccinated Australian children.
METHODS AND FINDINGS
Birth and vaccination records, IPD notifications, and hospitalisations were individually linked for children aged <5 years, born between 2001 and 2012 in 2 Australian states (New South Wales and Western Australia; 1.37 million children). Using Poisson regression models, we examined the association between PCV coverage, in small geographical units, and the incidence of (1) 7-valent PCV (PCV7)-type IPD; (2) all-cause pneumonia; and (3) pneumococcal and lobar pneumonia hospitalisation in undervaccinated children. Undervaccinated children received <2 doses of PCV at <12 months of age and no doses at ≥12 months of age. Potential confounding variables were selected for adjustment a priori with the assistance of a directed acyclic graph. There were strong inverse associations between PCV coverage and the incidence of PCV7-type IPD (adjusted incidence rate ratio [aIRR] 0.967, 95% confidence interval [CI] 0.958 to 0.975, p-value < 0.001), and pneumonia hospitalisations (all-cause pneumonia: aIRR 0.991 95% CI 0.990 to 0.994, p-value < 0.001) among undervaccinated children. Subgroup analyses for children <4 months old, urban, rural, and Indigenous populations showed similar trends, although effects were smaller for rural and Indigenous populations. Approximately 50% coverage of PCV7 among children <5 years of age was estimated to prevent up to 72.5% (95% CI 51.6 to 84.4) of PCV7-type IPD among undervaccinated children, while 90% coverage was estimated to prevent 95.2% (95% CI 89.4 to 97.8). The main limitations of this study include the potential for differential loss to follow-up, geographical misclassification of children (based on residential address at birth only), and unmeasured confounders.
CONCLUSIONS
In this study, we observed substantial indirect protection at lower levels of PCV coverage than previously described-challenging assumptions that high levels of PCV coverage (i.e., greater than 90%) are required. Understanding the association between PCV coverage and indirect protection is a priority since the control of vaccine-type pneumococcal disease is a prerequisite for reducing the number of PCV doses (from 3 to 2). Reduced dose schedules have the potential to substantially reduce program costs while maintaining vaccine impact.
Topics: Australia; Dose-Response Relationship, Drug; Hospitalization; Pneumococcal Infections; Pneumococcal Vaccines; Pneumonia; Vaccination Coverage; Vaccines, Conjugate
PubMed: 34343186
DOI: 10.1371/journal.pmed.1003733 -
BMC Health Services Research Jun 2022Caesarean sections account for roughly one third of all surgical procedures performed in low-income countries. Due to lack of standardised post-discharge follow-up...
BACKGROUND
Caesarean sections account for roughly one third of all surgical procedures performed in low-income countries. Due to lack of standardised post-discharge follow-up protocols and practices, most of available data are extracted from clinical charts during hospitalization and are thus sub-optimal for answering post-discharge outcomes questions. This study aims to determine enablers and barriers to returning to the hospital after discharge among women who have undergone a c-section at a rural district hospital in Rwanda.
METHODS
Women aged ≥ 18 years who underwent c-section at Kirehe District Hospital in rural Rwanda in the period March to October 2017 were prospectively followed. A structured questionnaire was administered to participants and clinical data were extracted from medical files between March and October 2017. At discharge, consenting women were given an appointment to return for follow-up on postoperative day 10 (POD 10) (± 3 days) and provided a voucher to cover transport and compensation for participation to be redeemed on their return. Study participants received a reminder call on the eve of their scheduled appointment. We used a backward stepwise logistic regression, at an α = 0.05 significance level, to identify enablers and barriers associated with post-discharge follow-up return.
RESULTS
Of 586 study participants, the majority (62.6%) were between 21-30 years old and 86.4% had a phone contact number. Of those eligible, 90.4% returned for follow-up. The predictors of return were counselling by a female data collector (OR = 9.85, 95%CI:1.43-37.59) and receiving a reminder call (OR = 16.47, 95%CI:7.07-38.38). Having no insurance reduced the odds of returning to follow-up (OR = 0.03, 95%CI:0.03-0.23), and those who spent more than 10.6 Euro for transport to and from the hospital were less likely to return to follow-up (OR = 0.14, 95%CI:0.04- 0.50).
CONCLUSION
mHealh interventions using calls or notifications can increase the post-discharge follow-up uptake. The reminder calls to patients and discharge counselling by a gender-matching provider had a positive effect on return to care. Further interventions are needed targeting the uninsured and patients facing transportation hardship. Additionally, association between counselling of women patients by a female data collector and greater return to follow-up needs further exploration to optimize counselling procedures.
Topics: Adult; Aftercare; Cesarean Section; Female; Follow-Up Studies; Hospitals, District; Humans; Patient Discharge; Pregnancy; Prospective Studies; Rwanda; Young Adult
PubMed: 35655212
DOI: 10.1186/s12913-022-08137-5 -
JMIR Perioperative Medicine Nov 2023Enhanced recovery after surgery (ERAS) protocols are patient-centered, evidence-based guidelines for peri-, intra-, and postoperative management of surgical candidates...
BACKGROUND
Enhanced recovery after surgery (ERAS) protocols are patient-centered, evidence-based guidelines for peri-, intra-, and postoperative management of surgical candidates that aim to decrease operative complications and facilitate recovery after surgery. Anesthesia providers can use these protocols to guide decision-making and standardize aspects of their anesthetic plan in the operating room.
OBJECTIVE
Research across multiple disciplines has demonstrated that clinical decision support systems have the potential to improve protocol adherence by reminding providers about departmental policies and protocols via notifications. There remains a gap in the literature about whether clinical decision support systems can improve patient outcomes by improving anesthesia providers' adherence to protocols. Our hypothesis is that the implementation of an electronic notification system to anesthesia providers the day prior to scheduled breast surgeries will increase the use of the already existing but underused ERAS protocols.
METHODS
This was a single-center prospective cohort study conducted between October 2017 and August 2018 at an urban academic medical center. After obtaining approval from the institutional review board, anesthesia providers assigned to major breast surgery cases were identified. Patient data were collected pre- and postimplementation of an electronic notification system that sent the anesthesia providers an email reminder of the ERAS breast protocol the night before scheduled surgeries. Each patient's record was then reviewed to assess the frequency of adherence to the various ERAS protocol elements.
RESULTS
Implementation of an electronic notification significantly improved overall protocol adherence and several preoperative markers of ERAS protocol adherence. Protocol adherence increased from 16% (n=14) to 44% (n=44; P<.001), preoperative administration of oral gabapentin (600 mg) increased from 13% (n=11) to 43% (n=43; P<.001), and oral celebrex (400 mg) use increased from 16% (n=14) to 35% (n=35; P=.006). There were no statistically significant differences in the use of scopolamine transdermal patch (P=.05), ketamine (P=.35), and oral acetaminophen (P=.31) between the groups. Secondary outcomes such as intraoperative and postoperative morphine equivalent administered, postanesthesia care unit length of stay, postoperative pain scores, and incidence of postoperative nausea and vomiting did not show statistical significance.
CONCLUSIONS
This study examines whether sending automated notifications to anesthesia providers increases the use of ERAS protocols in a single academic medical center. Our analysis exhibited statistically significant increases in overall protocol adherence but failed to show significant differences in secondary outcome measures. Despite the lack of a statistically significant difference in secondary postoperative outcomes, our analysis contributes to the limited literature on the relationship between using push notifications and clinical decision support in guiding perioperative decision-making. A variety of techniques can be implemented, including technological solutions such as automated notifications to providers, to improve awareness and adherence to ERAS protocols.
PubMed: 37921854
DOI: 10.2196/44139 -
BMC Medicine Oct 2022Varicella zoster virus (VZV) is one of the eight known human herpesviruses. Initial VZV infection results in chickenpox, while viral reactivation following a period of...
BACKGROUND
Varicella zoster virus (VZV) is one of the eight known human herpesviruses. Initial VZV infection results in chickenpox, while viral reactivation following a period of latency manifests as shingles. Separate vaccines exist to protect against both initial infection and subsequent reactivation. Controversy regarding chickenpox vaccination is contentious with most countries not including the vaccine in their childhood immunization schedule due to the hypothesized negative impact on immune-boosting, where VZV reactivation is suppressed through exogenous boosting of VZV antibodies from exposure to natural chickenpox infections.
METHODS
Population-level chickenpox and shingles notifications from Thailand, a country that does not vaccinate against either disease, were previously fitted with mathematical models to estimate rates of VZV transmission and reactivation. Here, multiple chickenpox and shingles vaccination scenarios were simulated and compared to a model lacking any vaccination to analyze the long-term impacts of VZV vaccination.
RESULTS
As expected, simulations suggested that an introduction of the chickenpox vaccine, at any coverage level, would reduce chickenpox incidence. However, chickenpox vaccine coverage levels above 35% would increase shingles incidence under realistic estimates of shingles coverage with the current length of protective immunity from the vaccine. A trade-off between chickenpox and shingles vaccination coverage was discovered, where mid-level chickenpox coverage levels were identified as the optimal target to minimize total zoster burden. Only in scenarios where shingles vaccine provided lifelong immunity or coverage exceeded current levels could large reductions in both chickenpox and shingles be achieved.
CONCLUSIONS
The complicated nature of VZV makes it impossible to select a single vaccination scenario as universal policy. Strategies focused on reducing both chickenpox and shingles incidence, but prioritizing the latter should maximize efforts towards shingles vaccination, while slowly incorporating chickenpox vaccination. Alternatively, countries may wish to minimize VZV complications of both chickenpox and shingles, which would lead to maximizing vaccine coverage levels across both diseases. Balancing the consequences of vaccination to overall health impacts, including understanding the impact of an altered mean age of infection for both chickenpox and shingles, would need to be considered prior to any vaccine introduction.
Topics: Chickenpox; Chickenpox Vaccine; Child; Herpes Zoster; Herpes Zoster Vaccine; Herpesvirus 3, Human; Humans; Vaccination; Vaccines, Attenuated
PubMed: 36209074
DOI: 10.1186/s12916-022-02534-7