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The Challenge of Methicillin-Resistant Staphylococcus aureus Prevention in Hemodialysis Therapy

SEMINARS IN dIALYSIS 2012年第1期25卷 42-49页

作者： Parker, Mark G. doebbeling, Bradley N. Maine Med Ctr Div Nephrol & Transplantat Portland ME 04102 USA Indianapolis VAMC VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Regenstrief Inst Hlth Care Indianapolis IN 46202 USA Indiana Univ Ctr Hlth Serv & Outcomes Res Indianapolis IN 46204 USA Indiana Univ Sch Med Dept Med Indianapolis IN USA

Methicillin-resistant Staphylococcus aureus (MRSA) infections have challenged care process and resource utilization in the acute hospital care setting for nearly 30 years. These infections have become important causes of morbidity, mortality, and a source of concern in the primary and emergency care context over the past decade. As individuals receiving recurrent therapy with features of both ambulatory care and acute care, hemodialysis patients are exposed to numerous opportunities for MRSA acquisition. Surprisingly, high prevalence rates for MRSA colonization have been demonstrated for both hemodialysis patients and their care providers. The necessity of vascular access and the persistent high prevalence of endovascular catheter use among patients repeatedly exposed to healthcare settings provide the perfect milieu for the troubling rates of MRSA infection, particularly bloodstream infections, in outpatient dialysis care. dialysis industry shifts, including increased requirements for compliance and reporting in other areas of dialysis care, tax resources for infection prevention processes. Multifaceted strategies that include reassessment of vascular access care, attention to the interruption of MRSA transmission dynamics, and emphasis on organizational learning processes are needed to accomplish a meaningful reduction in the morbidity, mortality, and cost associated with MRSA infections in dialysis care.

关键词： METHICILLIN-resistant staphylococcus aureus STAPHYLOCOCCUS aureus infections PREVENTION HEMOdIALYSIS patients dISEASE prevalence OUTPATIENT medical care

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An Expanded View of Self-Management: Patients' Perceptions of Education and Support in an Intervention for Chronic Musculoskeletal Pain

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PAIN MEdICINE 2012年第8期13卷 1018-1028页

作者： Matthias, Marianne S. Miech, Edward J. Myers, Laura J. Sargent, Christy Bair, Matthew J. Roudebush VAMC VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN 46202 USA Regenstrief Inst Inc Indianapolis IN USA Indiana Univ Purdue Univ Dept Commun Studies Indianapolis IN 46202 USA Indiana Univ Sch Med Dept Emergency Med Indianapolis IN USA Indiana Univ Sch Med Dept Med Indianapolis IN USA

Objectives. Chronic pain is prevalent, costly, and is associated with profound psychological effects. Although pain is prevalent in returning veterans of the recent military conflicts in Afghanistan and Iraq (Operation Iraqi Freedom/Operation Enduring Freedom/Operation New dawn [OEF/OIF/ONd] Veterans), little is known about chronic pain in these patients. This study's objective was to ascertain perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/ONd veterans with chronic musculoskeletal pain (Evaluation of Stepped Care for Chronic Pain [ESCAPE]). design. Qualitative interviews were conducted with 26 patients in the intervention arm of ESCAPE (21% of total intervention patients) to determine patients' experiences with and perceptions of the intervention. Patients were purposefully sampled to include treatment responders (defined as =30% reduction in pain-related disability or pain severity), nonresponders, and noncompleters (completed <50% of trial). Qualitative analysis was guided by grounded theory. Results. Both responders and nonresponders discussed the importance of the self-management education they received. Of particular significance, patients identified the nurse care manager who administered the intervention as being integral to patients' ability to self-manage their chronic pain. Patients described important ways in which the nurse facilitated their self-management, reported under three themes: 1) helping patients find what works for their pain;2) holding patients accountable for their pain management;3) motivating and providing emotional support to patients. Conclusions. Results corroborate previous work and suggest that current conceptualizations of self-management are incomplete. A model is proposed that not only depicts self-management as involving more than activities and strategies, but also acknowledges the central role of relationships and support in pain self-management.

关键词： Chronic Pain Self-Management Qualitative Research Patient-Provider Communication Veterans

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Burden of Illness and Treatment Patterns for Patients with Fibromyalgia

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PAIN MEdICINE 2012年第10期13卷 1366-1376页

作者： Robinson, Rebecca L. Kroenke, Kurt Mease, Philip Williams, david A. Chen, Yi d'Souza, deborah Wohlreich, Madelaine McCarberg, Bill Eli Lilly & Co Lilly Res Labs Indianapolis IN 46285 USA Indiana Univ Indianapolis IN 46204 USA Regenstrief Inst Hlth Care Indianapolis IN USA VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Swedish Med Ctr Seattle Rheumatol Associates Seattle WA USA Univ Washington Seattle WA 98195 USA Univ Michigan Chron Pain & Fatigue Res Ctr Ann Arbor MI 48109 USA PharmaNet i3 Indianapolis IN USA PharmaNet i3 Ann Arbor MI USA Kaiser Permanente Escondido CA USA

Objective. This study was designed to describe burden of illness and treatment patterns, and to examine the patient, physician, and care factors associated with the treatment choices of individuals receiving new prescriptions for fibromyalgia (FM). design. This is a baseline assessment of the Real-World Examination of Fibromyalgia: Longitudinal Evaluation of Costs and Treatments (REFLECTIONS), a prospective observational study. Baseline data (including a physician survey, a patient visit form, and computer-assisted telephone interviews) were collected from July 2008 through May 2010 in 58 care settings in the United States, including Puerto Rico. Results. Patients (N = 1,700) were mostly female (94.6%) and white (82.9%). Mean age was 50.4 years and mean duration of illness was 5.6 years. Mean Fibromyalgia Impact Questionnaire total score was 54.4 (range 080), and Brief Pain Inventory average pain severity level was 5.5 (range 010). Patients reported high annual health care use and numerous work limitations related to FM. Patients were taking 182 unique types of medications prescribed for FM, including duloxetine (26.8%), nonsteroidal anti-inflammatory drugs (26.6%), pregabalin (24.5%), opioids (24.2%), tramadol (15.3%), benzodiazepines (15.2%), cyclobenzaprine (12.9%), milnacipran (8.9%), and others. Most patients took more than one medication concurrently (77.8%). Type of current medications used was most strongly associated with medication history and physician specialty. Conclusions. Burden of illness was high for patients with FM, and treatment patterns were highly variable. Importantly, the treatments with the most evidence to support their use were not always the most frequently chosen.

关键词： Fibromyalgia Observational duloxetine Pregabalin Milnacipran

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Evaluation of an Android-based mHealth system for population surveillance in developing countries

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JOURNAL OF THE AMERICAN MEdICAL INFORMATICS ASSOCIATION 2012年第4期19卷 655-659页

作者： Rajput, Zeshan A. Mbugua, Samuel Amadi, david Chepngeno, Viola Saleem, Jason J. Anokwa, Yaw Hartung, Carl Borriello, Gaetano Mamlin, Burke W. Ndege, Samson K. Were, Martin C. Regenstrief Inst Inc Dept Med Informat Indianapolis IN 46202 USA Indiana Univ Sch Med Dept Gen Internal Med & Geriatr Indianapolis IN USA USAID Acad Model Providing Access Hlth Care USAID Eldoret Kenya VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Regenstrief Inst Inc Dept Hlth Serv Res Indianapolis IN 46202 USA IUPUI Dept Elect & Comp Engn Indianapolis IN USA Univ Washington Dept Comp Sci & Engn Seattle WA 98195 USA Moi Univ Sch Med Eldoret Kenya Moi Univ Sch Publ Hlth Eldoret Kenya

Objective In parts of the developing world traditionally modeled healthcare systems do not adequately meet the needs of the populace. This can be due to imbalances in both supply and demand-there may be a lack of sufficient healthcare and the population most at need may be unable or unwilling to take advantage of it. Home-based care has emerged as a possible mechanism to bring healthcare to the populace in a cost-effective, useful manner. This study describes the development, implementation, and evaluation of a mobile device-based system to support such services. Materials and Methods Mobile phones were utilized and a structured survey was implemented to be administered by community health workers using Open data Kit. This system was used to support screening efforts for a population of two million persons in western Kenya. Results Users of the system felt it was easy to use and facilitated their work. The system was also more cost effective than pen and paper alternatives. discussion This implementation is one of the largest applications of a system utilizing handheld devices for performing clinical care during home visits in a resource-constrained environment. Because the data were immediately available electronically, initial reports could be performed and important trends in data could thus be detected. This allowed adjustments to the programme to be made sooner than might have otherwise been possible. Conclusion A viable, cost-effective solution at scale has been developed and implemented for collecting electronic data during household visits in a resource-constrained setting.

关键词： Clinical decision support communication data exchange developing/using clinical decision support (other than diagnostic) and guideline systems developing/using computerized provider order entry integration across care settings (inter and intra-enterprise) measuring/improving patient safety and reducing medical errors mobile devices patient facing applications

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Testing the PHQ-9 Interview and Observational Versions (PHQ-9 OV) for MdS 3.0

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JOURNAL OF THE AMERICAN MEdICAL dIRECTORS ASSOCIATION 2012年第7期13卷 618-625页

作者： Saliba, debra diFilippo, Suzanne Edelen, Maria Orlando Kroenke, Kurt Buchanan, Joan Streim, Joel UCLA Jewish Home Borun Ctr Gerontol Res Los Angeles CA USA RAND Corp Greater Los Angeles VA GRECC Santa Monica CA USA RAND Corp HSR&D Ctr Excellence Santa Monica CA USA Philadelphia Vet Affairs Med Ctr Mental Illness Res Educ & Clin Ctr Vet Integrated Serv Network 4 Philadelphia PA USA Univ Penn Dept Psychiat Geriatr Psychiat Sect Philadelphia PA 19104 USA RAND Corp Boston MA USA Richard Roudebush VA Med Ctr Ctr Implementing Evidence Based Practice Indianapolis IN USA Harvard Univ Sch Med Dept Hlth Care Policy Boston MA 02115 USA Univ Penn Perelman Sch Med Geriatr Psychiat Sect Philadelphia PA 19104 USA Philadelphia VA Med Ctr VISN Mental Illness Res Educ & Clin Ctr 4 Philadelphia PA USA

Objectives: To test the feasibility and validity of the Patient Health Questionnaire-9 item interview (PHQ-9) and the newly developed Patient Health Questionnaire Observational Version (PHQ-9 OV) for screening for mood disorder in nursing home populations. Methods: The PHQ-9 was tested as part of the national Minimum data Set 3.0 (MdS 3.0) evaluation study among 3822 residents scheduled for MdS 2.0 assessments. Residents from 71 community nursing homes (NHs) in eight states were randomly included in a feasibility sample (n = 3258) and a validation sample (n = 418). Each resident's ability to communicate determined whether the PHQ-9 interview or the PHQ-9 OV was initially attempted. In the validation sample, trained research nurses administered the instruments. For residents in the validation sample without severe cognitive impairment (3 MS >= 30) agreement between PHQ-9 and the modified Schedule for Affective disorders and Schizophrenia (m-SAdS) was measured with weighted kappas (kappa). For residents with severe cognitive impairment (3MS < 30), agreement between PHQ-9 interview or PHQ-9 OV and the Cornell Scale for depression in dementia (Cornell Scale) was measured using correlation coefficients. Staff impressions were obtained from an anonymous survey mailed to all MdS assessors. Results: The PHQ-9 was completed in 86% of the 3258 residents in the feasibility sample. In the validation sample, the agreement between PHQ-9 and m-SAdS was very good (weighted kappa = 0.69, 95% CI = 0.61-0.76), whereas agreement between MdS 2.0 and m-SAdS was poor (weighted kappa = 0.15, 95% CI = 0.06-0.25). Likewise, in residents with severe cognitive impairment, PHQ correlations with the criterion standard Cornell Scale were superior to the MdS 2.0 for both the PHQ-9 (0.63 vs 0.34) and the PHQ-9 OV (0.84 vs 0.28). Eighty-six percent of survey respondents reported that the PHQ-9 provided new insight into residents' mood. The average time for completing the PHQ-9 interview was 4 minute

关键词： Mood nursing home assessment Minimum data Set depression observation interview PHQ-9

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deriving Competencies for Mentors of Clinical and Translational Scholars

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CTS-CLINICAL ANd TRANSLATIONAL SCIENCE 2012年第3期5卷 273-280页

作者： Abedin, Zainab Biskup, Ewelina Silet, Karin Garbutt, Jane M. Kroenke, Kurt Feldman, Mitchell d. McGee, Richard, Jr. Fleming, Michael Pincus, Harold Alan Columbia Univ New York Presbyterian Hosp Irving Inst Clin & Translat Res Dept PsychiatMed Ctr New York NY 10027 USA RAND Corp New York NY USA Columbia Univ Med Ctr Dept Psychiat Psychiat Univ Clin Zurich Switzerland Univ Wisconsin Inst Clin & Translat Res Madison WI USA Washington Univ Inst Clin & Translat Sci St Louis MO USA Indiana Univ Regenstrief Inst Indiana Clin & Translat Res Inst Indianapolis IN 46204 USA VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Univ San Francisco Dept Gen Internal Med San Francisco CA 94117 USA Fac Recruitment & Profess Dev Chicago IL USA Northwestern Univ Feinberg Sch Med Chicago IL 60611 USA

Although the importance of research mentorship has been well established, the role of mentors of junior clinical and translational science investigators is not clearly defined. The authors attempt to derive a list of actionable competencies for mentors from a series of complementary methods. We examined focus groups, the literature, competencies derived for clinical and translational scholars, mentor training curricula, mentor evaluation forms and finally conducted an expert panel process in order to compose this list. These efforts resulted in a set of competencies that include generic competencies expected of all mentors, competencies specific to scientists, and competencies that are clinical and translational research specific. They are divided into six thematic areas: (1) Communication and managing the relationship, (2) Psychosocial support, (3) Career and professional development, (4) Professional enculturation and scientific integrity, (5) Research development, and (6) Clinical and translational investigator development. For each thematic area, we have listed associated competencies, 19 in total. For each competency, we list examples that are actionable and measurable. Although a comprehensive approach was used to derive this list of competencies, further work will be required to parse out how to apply and adapt them, as well future research directions and evaluation processes. Clin Trans Sci 2012;Volume 5: 273280

关键词： mentoring mentor competencies translational

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Paper persistence, workarounds, and communication breakdowns in computerized consultation management

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INTERNATIONAL JOURNAL OF MEdICAL INFORMATICS 2011年第7期80卷 466-479页

作者： Saleem, Jason J. Russ, Alissa L. Neddo, Adam Blades, Paul T. doebbeling, Bradley N. Foresman, Brian H. Roudebush VA Med Ctr VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Regenstrief Inst Inc Indianapolis IN USA Indiana Univ Ctr Hlth Serv & Outcomes Res Indianapolis IN 46204 USA IUPUI Dept Elect & Comp Engn Indianapolis IN USA Purdue Univ Coll Pharm Dept Pharm Practice W Lafayette IN 47907 USA Roudebush VA Med Ctr Sleep Med Program Indianapolis IN USA IU Sch Med Dept Med Indianapolis IN USA

Objective: The consultation request process between primary care and specialty services often contains paper-based components that may be inefficient and difficult to track. Other barriers may include workarounds and communication breakdowns with the potential to adversely impact delivery of quality medical care. We investigated current challenges to the electronic outpatient consult management process in the United States Veterans Health Administration (VHA). design: We conducted ethnographic observation and semi-structured interviews in nine different specialty clinics and three primary care clinics in a large, tertiary Veterans Affairs Medical center (vaMC). We also performed a national-level query of 'electronic error and enhancement requests' (E3Rs) related to the consult package in the va's electronic health record (EHR) submitted over a 5-year period (2005-2009). Measurements: Two researchers recorded the observable interactions and interview responses of 16 healthcare workers related to their work with consultations. Two separate coding schemes were applied to both the observational and the interview data. E3Rs from the national query were reviewed and categorized based on the nature of the enhancement requests. Results: We identified several examples of paper persistence, as well as workarounds, communication breakdowns, and redundancies in computerized consult management. An analysis of enhancement requests for the consults also revealed three broad needs related to reporting, configuration or customization, and user interface enhancements. Conclusion: Understanding these challenges to the current consult management process is important to help design enhanced informatics tools integrated into workflow to support coordination of care and tracking of consults requests. Published by Elsevier Ireland Ltd

关键词： Workarounds Electronic health records [MeSH] Computerized medical record [MeSH] Consultation and referral [MeSH] Human information processing [MeSH]

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design and Implementation of a Hospital-based Usability Laboratory: Insights from a department of Veterans Affairs Laboratory for Health Information Technology

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JOINT COMMISSION JOURNAL ON QUALITY ANd PATIENT SAFETY 2012年第12期38卷 531-+页

作者： Russ, Alissa L. Weiner, Michael Russell, Scott A. Baker, darrell A. Fahner, W. Jeffrey Saleem, Jason J. Richard L Roudebush VA Med Ctr VAMC Vet Affairs Hlth Serv Res & Dev Serv Ctr Excellence Implementing Evidence Based Practi Indianapolis IN 46202 USA Regenstrief Inst Inc Indianapolis IN USA Purdue Univ Dept Pharm Practice W Lafayette IN 47907 USA Hlth Serv Res & Dev Serv HFP 04 148 Ctr Excellence Implementing Evidence Based Practi Dept Vet Affairs Vet Hlth Adm Indianapolis IN USA Regenstrief Inst Inc Ctr Hlth Serv Res Indianapolis IN USA Indiana Univ Ctr Hlth Serv & Outcomes Res Indianapolis IN 46204 USA Indiana Univ Sch Med Med Indianapolis IN 46202 USA VA HSR&D CIEBP Indianapolis IN USA Richard L Roudebush VAMC Indianapolis IN USA Indiana Univ Purdue Univ Dept Elect & Comp Engn Indianapolis IN 46202 USA

Background: Although the potential benefits of more usable health information technologies (HIT) are substantial-reduced HIT support costs, increased work efficiency, and improved patient safety-human factors methods to improve usability are rarely employed. The US department of Veterans Affairs (va) has emerged as an early leader in establishing usability laboratories to inform the design of HIT, including its electronic health record. Experience with a usability laboratory at a va Medical center provides insights on how to design, implement, and leverage usability laboratories in the health care setting. Implementation: The va Health Services Research and development Service Human-Computer Interaction & Simulation Laboratory emerged as one of the first va usability laboratories and was intended to provide research-based findings about HIT designs. This laboratory supports rapid prototyping, formal usability testing, and analysis tools to assess existing technologies, alternative designs, and potential future technologies. Results of Implementation: Although the laboratory has maintained a research focus, it has become increasingly integrated with va operations, both within the medical center and on a national va level. With this resource, data-driven recommendations have been provided for the design of HIT applications before and after implementation. Conclusion: The demand for usability testing of HIT is increasing, and information on how to develop usability laboratories for the health care setting is often needed. This article may assist other health care organizations that want to invest in usability resources to improve HIT. The establishment and utilization of usability laboratories in the health care setting may improve HIT designs and promote safe, high-quality care for patients.

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A national collaborative for reducing health care-associated infections: Current initiatives, challenges, and opportunities

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AMERICAN JOURNAL OF INFECTION CONTROL 2011年第8期39卷 685-689页

作者： Flanagan, Mindy E. Welsh, Catherine Amber Kiess, Chris Hoke, Shawn doebbeling, Bradley N. Indiana Univ Ctr Hlth Serv & Outcomes Res Indianapolis IN 46204 USA Regenstrief Inst Inc Indianapolis IN USA US Dept Vet Affairs Hlth Serv Res & Dev Ctr Excellence Indianapolis IN USA Roudebush VAMC VA HSR&D Ctr Implementing Evidence Based Practice Indianapolis IN USA Indiana Univ Sch Med Dept Med Indianapolis IN USA

There has been increasing interest and an upsurge in efforts to prevent hospital-associated infections (HAIs), a leading cause of death in the United States. This study was conducted to assess current strategies and efforts of HAI reduction initiatives in hospitals. HAI reduction initiatives and factors influencing institutional participation in these initiatives were categorized. data were collected via open-ended questions on surveys performed in 5 different HAI collaboratives. Thematic analysis of the coded qualitative data was conducted. A total of 1,212 health care professionals from 33 different hospitals participated. Improving hand hygiene was the most frequently mentioned HAI reduction initiative implemented in the previous year. Initiatives for reducing central line or central venous catheter infections and ventilator-associated pneumonia also were commonly cited. The most frequently mentioned challenges to implementing HAI reduction initiatives included poor adherence, insufficient resources, staffing problems, lack of culture change, no impetus to change, and issues related to staff and patient education. Many respondents identified engaging physicians as particularly challenging. These findings suggest that consistently improving hand hygiene remains a widespread problem for reducing HAIs and sustaining this type of behavioral change is difficult. Furthermore, ensuring staff and physician engagement and compliance in HAI reduction efforts remains challenging for most hospitals.

关键词： Hospital-acquired infections infection prevention and control

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Paper Persistence and Computer-based Workarounds with the Electronic Health Record in Primary Care

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Proceedings of the Human Factors and Ergonomics Society Annual Meeting 2011年第1期55卷 660 - 664页

作者： Jason J. Saleem Mindy Flanagan Laura G. Militello Nicole Arbuckle Alissa L. Russ A. Lucile Burgo-Black Bradley N. doebbeling VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis INDepartment of Electrical & Computer Engineering IUPUI Indianapolis IN Indiana University (IU) Center for Health Services & Outcomes Research Indianapolis IN Applied Decision Science Kettering OH University of Dayton Research Institute Dayton OH VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis INIndiana University (IU) Center for Health Services & Outcomes Research Indianapolis INDepartment of Pharmacy Practice Purdue University College of Pharmacy West Lafayette IN VA Connecticut Healthcare SystemYale University School of Medicine New Haven CT VA HSR&D Center on Implementing Evidence-Based Practice Roudebush VAMC Indianapolis INIndiana University (IU) Center for Health Services & Outcomes Research Indianapolis INDepartment of Medicine IU School of Medicine Indianapolis IN

With the United States national goal and incentive program to transition from paper to electronic health records (EHRs), healthcare organizations are increasingly implementing EHRs and other related health information technology (IT). However, in institutions which have long adopted these computerized systems, such as the Veterans Health Administration, healthcare workers continue to rely on paper to complete their work. Furthermore, insufficient EHR design also results in computer-based workarounds. Using direct observation with opportunistic interviewing, we investigated the use of paper- and computer-based workarounds to the EHR with a multi-site study of 54 healthcare workers, including primary care providers, nurses, and other healthcare staff. Our analysis revealed several paper- and computer-based workarounds to the va’s EHR. These workarounds, including clinician-designed information tools, provide evidence for how to enhance the design of the EHR to better support the needs of clinicians.

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